Contract negotiations between health plans and providers, primarily hospitals, were mild in 2002 and 2003, compared to how they played out in 2000 and 2001, according to a study by the Center for Studying Health System Change.

Every two years, HSC researchers visit 12 "nationally representative health care markets" to track any changes.What they found this time was plans that were resigned to the idea that providers have the upper hand.

"The balance of power has shifted to providers — especially hospitals — and health plans in many cases are going along with demands for higher payment rates and better contract terms," says Paul Ginsburg, PhD, HSC's president. "Health plans are passing along higher costs through higher premiums, and employers and consumers appear to be the ultimate losers."

Increased consolidation among hospitals and physician groups is cited as one of the reasons providers have more clout.

Strong consumer demand for broad provider networks also plays a part — health plans find it harder to use the threat of exclusion from a network as a negotiating ploy. Further, certain providers enjoy what the study calls "must-have" status in health plan networks.

"Indeed," says the study, "while contract negotiations remain difficult, most plans now cautiously approach potential showdowns with a better understanding of the formidable odds they face in trying to win them." However, as the study suggests, the balance of power could swing back toward health plans.

The study cites an instance where employers — including Microsoft, Boeing, Starbucks, and Nordstrom — became involved in a dispute between Aetna and a Seattle-based hospital system, Swedish Health Services. "The dispute underscored the potential for employers to play an active role in negotiations, particularly by using the [news] media," the study states.

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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.