Patients who change health plans may face adverse clinical and financial effects as a result, according to a new study. Researchers at the University of California — Davis found that "the first year of insurance was associated with a higher risk of not get-ting a mammogram, a higher risk of avoidable hospitalization, greater likelihood of visiting a physician, and higher expenditures, especially for testing."

The study, published in the September/October issue of the Annals of Family Medicine, says that 20 percent of consumers switch health plans each year. The frequency with which enrollees switch has long been cited as a possible reason that there is not more investment in disease management. Patients who benefit from one insurer's disease management program may jump to a different company in a few years.

This study — "On Being New to an Insurance Plan: Health Care Use Associated With the First Years in a Health Insurance Plan" — suggests that such mobility is not good for consumers either. The data, from an IPA in Rochester, N.Y., involved 335,547 adults from 1996 through 1999.

Exactly why costs increase is difficult to pin down.

The authors state: "The higher adjusted expenditures in newly insured patients might reflect either decreased efficiency of care delivery or appropriate catch-up in care, especially for those without previous health insurance.

"Because we could not distinguish between persons switching health plans and those not previously insured, we were unable to develop a reliable algorithm for the claims data that would allow distinction between these two possibilities."

They note other studies showing that patients' satisfaction drops when they are forced to go hunting for another insurer.

Employers may get less than they bargain for in the insurance rebidding process.

"Given the relative stability of the health care insurance market in Rochester, it is likely that these findings ... underestimate ... effects in more competitive insurance environments with more frequent insurance changes."

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.