Though the State Children's Health Insurance Program managed to avoid cuts in fiscal year 2002, strains are beginning to show that may mean beneficiaries will face copayments for medications.

An Urban Institute report indicates that CHIP did remarkably well in fiscal year 2002, despite state budget deficits and growing enrollment.

That report, aptly titled "SCHIP Dodges the First Budget Ax," looks at the ups and downs of programs in 13 states that account for 64 percent of total CHIP enrollment, and finds that none cut benefits packages this year, though five are either considering or have already imposed increased cost sharing.

In Texas, for instance, the lowest-income families (those below the poverty level) are now charged $3 for an ER visit and $3 for each brand-name prescription.

"Copayments rise by income level to the point where the highest income families (186–200 percent of poverty) now pay $50 per ER visit and $20 per brand-name prescription, in contrast to previous levels of $35 and $10" respectively, the report notes.

Alabama, Massachusetts, New Jersey, and Washington are considering imposing higher copayments. (The report also tracks programs in California, Colorado, Florida, Michigan, Minnesota, Mississippi, New York, and Wisconsin.)

Despite some problems, CHIP fared well. Some reasons being cited are that the program is widely viewed as successfully addressing a vital need; is not seen as overly costly, especially compared to Medicaid; and draws a large amount of matching federal funds, making it difficult to justify program cuts.

Still, whether CHIP can continue to hold its own is questionable. The report notes: "No governor or legislator wants to cut a program that explicitly serves children, especially during an election year." That will be a moot point after this month.

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.