Gatekeeping, cost shifting, and disease managing have all been tried with various degrees of success, at various times, to control spending. In the wings: information technology and consumer-directed health care. Plans are starting to experiment with paying people to make lifestyle changes.

Blue Shield of California has launched a project it calls Healthy Lifestyle Rewards for about 25,000 members who can receive up to $200 for participating.

Members sign on to an Internet site and fill out a questionnaire that pinpoints health risks that could result in chronic disease.

The four areas for possible improvement are diet, exercise, stress, and smoking. While members don't have to show improvement, they do have to log on regularly over the course of the 10-month program and record their activities. About 1,000 employees of San Mateo County are eligible for the free program.

"Healthy Lifestyle Rewards is a bold step that will help us be more effective in managing health, preventing chronic disease, and improving employee productivity," says Paul Hackleman, the county's benefits manager.

Meanwhile, PacifiCare has launched its own version of an online lifestyle improvement program in which participants accumulate credits in order to enter quarterly drawings in which they can win such prizes as treadmills or mountain bikes. Credits can also be used for discounts on various health-related items.

Employers, for their part, have the option of offering additional incentives, such as lower health insurance premiums or copayments.

"It's similar to auto insurance," says Brad Bowlus, PacifiCare's president and CEO. "Consumers who maintain an excellent driving record receive lower auto insurance premiums. We are translating that same concept into the health care environment and are actively encouraging our members to maintain better health.

"HealthCredits can serve as a motivational tool for employees who have the opportunity to see their health insurance ... premiums decrease through more active participation in their own health," Bowlus suggests.

In the heartland, Minneapolis/Saint Paul residents who are members of HealthPartners can have part of their health club monthly dues paid by the insurer if they work out at least eight times a month. Also, those who participate in the Weight Watchers online program are eligible for a reduced Weight Watchers fee.

Meanwhile, in Pennsylvania, people enrolled in one of Highmark's Medicare products are also getting incentives to improve their lifestyles.

Those in FreedomBlue, Security 65, or Security Blue can obtain membership in free fitness and exercise classes under a program called SilverSneakers.

"The SilverSneakers program helps members maintain and improve their balance, strength, and flexibility — all of which help with everyday activities," says Judith Black, MD, Highmark's medical director for senior products.

"Our members will have access to classes designed for older adults at a variety of locations, such as fitness centers and senior centers."

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.