Plan: Humana
Strategy: Humana rewires its systems, in the process, rebuilding relationships with patients and providers
Progress: Launches in Memphis on Jan. 1

Humana Chairman David Jones told a group in June that he was reinventing the company he cofounded — again. "Sometimes," he said, "you need to thoughtfully abandon yesterday's success."

The nursing home company-turned-hospital operator-turned-managed care company is now pursuing a business model that uses the Internet to change the way insurers interact with members and physicians. The first evidence of this will turn up in Memphis, where Humana intends to launch a "digital health plan" on Jan. 1.

Jonathan T. Lord, MD, Humana's chief clinical strategy and innovation officer, says the plan, which eventually will be rolled out in other markets, is designed to ease interactions with physicians, consumers, employers, and brokers — removing hassles while saving the company significant administrative expense.

It's not just a matter of "web-ifying" existing business, as Lord puts it. "This plan is built from the ground up, with a new way of thinking through some of the processes that support the work. That, coupled with an entirely new claims-processing engine that allows for employers and individuals to customize benefits and adjudicate claims instantly, and provide up-to-date eligibility information — those are huge changes in the way business is going to be done."

Eligibility, of course, powers the whole claims train, and employers can use the system to add and delete members instantly. They'll also be able to pay premiums electronically. For physicians, "As long as they or their staffs do an online eligibility check and we tell them the member is eligible, we're not going to deny a claim later because of membership status," says Lord. "We're trying to deal with some of the things that have frustrated physicians."

For members, the system offers online enrollment, as well as the ability to check benefits and claims statuses, print ID cards, and chat with a customer service representative. But for some patients, the real value of Humana's new system may be in its medically oriented applications.

In time, the company will create, for each patient, a personal health profile — an online compilation of one's entire claims history. From a convenience standpoint, it will save patients the drudgery of filling out information on a clipboard in the doctor's office. Instead, with the patient's permission, the physician can download a patient's health profile, thus answering all the questions on the clipboard. From a safety standpoint, any information a patient might have forgotten to write down — medications being taken, for instance — is there for the physician to see.

Members can add personal health information. An example, says Lord, is herbal-supplement use. "That information can be uploaded to the profile, and the system will look for interactions with any medications being taken. That's something we know often isn't reported to physicians.

"It's progressive and integrated systems thinking," he says, "instead of looking at this in a silo fashion."

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.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

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?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

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.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

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.