Health plan enrollees who take their complaints about coverage issues to an independent reviewer have a good chance of getting HMO decisions overturned — but very few people take advantage of this system. One expert says that this is an indication that a Patients' Bill of Rights might not raise insurance premiums as much as many in the industry have stated it would.

Researchers at Georgetown University's Institute for Health Care Research and Policy examined the external review process in 41 states and Washington, D.C., and found that the boards overturned 45 percent of HMO rulings denying coverage.

The system is not used much, however. In New York, for instance, the state with the most appeals, only 10.7 cases per 100,000 were filed.

The findings of the report — "Assessing State External Review Programs and the Effects of Pending Federal Patients' Rights Legislation" — released by the Kaiser Family Foundation, may have taken policy makers by surprise, but it sure wasn't news to Ron Pollack, president of Families USA, a consumer health advocacy organization. He believes that consumers are intimidated by the appeals process.

"I think that these external, independent appeals are extremely important, because they provide an opportunity for recourse when somebody feels that they've been improperly denied care," says Pollack. "Unfortunately, this recourse is a meaningless remedy if the consumer does not have somebody available to help him with these hearings."

When Pollack refers to help, he means having someone actually represent consumers in appeals.

"For this very important right to an appeal to become meaningful, it will become increasingly important for consumers to have access to ombudsmen and other advocates who can help them present their claims as effectively as possible," says Pollack.

The report found that one reason many people do not appeal to a third-party review board is that many states mandate that they go through a health plan's internal review process first.

There was also the matter of filing fees and the minimum limits on the amount that must be in dispute.

"External review programs have earned broad support but they are not being widely used," says Drew E. Altman, president of the Kaiser Family Foundation. "The low number of cases suggests that a Patients' Bill of Rights might not raise insurance premiums as much as some have feared."

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.