Oregon's governor signed a bill creating a reference formulary for Medicaid. The new law bases reimbursement for all medications in a class on the cost of a chosen "reference" drug in that class.... Pharmaceutical Research and Manufacturers of America is suing the Centers for Medicare and Medicaid Services (formerly HCFA) for approving Maine's new drug-discount program. PhRMA claims Healthy Maine violates Medicaid laws because manufacturers must shoulder the cost of rebates.... Weiss Ratings reports that fewer than three dozen large plans are driving HMO-industry profits, which totaled $908 million in 2000, through September.... Aetna will shed much of its small-employer (50 or fewer employees) business, as part of its financial strategy, the Hartford Courant reports.... On a per-capita basis, inpatient admissions have not changed in 40 years, according to an Agency for Healthcare Research and Quality study.... The same can not be said for ER visits; federal statistics indicate a 14-percent increase in annual ER visits from 1992 to 1999. Considering that the number of hospitals remained static during the '90s but Census figures show an 11-percent U.S. population growth from 1990 to 2000, ERs are maxed out.
Managed Care’s Top Ten Articles of 2016
There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.
They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?
A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.
More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.