When the National Committee for Quality Assurance issued its lists of the 10 best Medicare and Medicaid managed care health plans last month, the announcement garnered a lot of attention. Which was part of what the organization wanted. John Rother, the AARP's director of policy and strategy, says,"For consumers the message is still: Do your homework. Health plans are not all the same. Make a list of what is important to you and find information from NCQA...."

However, there have been questions raised as to whether employers pay enough attention to NCQA ratings, let alone the older and/or poorer populations served by Medicare and Medicaid.

"We hope that packaging this as a top ten list will increase consumer attention, but any time you put new information into the market there is a learning curve for consumers and you always have to start at the bottom," responds NCQA spokesman Brian Schilling. "It's a learning curve, certainly, and we're expecting that in a few years, we'll see a much different picture. Every time one of the plans on this list advertises that it offers higher quality care or made our top ten list (and they will), it raises awareness and helps educate the market. Might be slow going, but over time it will move the market in the right direction."

The Centers for Medicare & Medicaid Services requires all Medicare Advantage plans to publicly report their results through the NCQA, and more than 100 Medicaid plans now do the same.

"We have a CMS contract to collect data from Medicare plans and they allow us to use the data to generate reports like this," says Schilling. "The 100 Medicaid plans that are referenced above give us their data voluntarily. Those data are available in NCQA's Quality Compass, for public consumption."

Still, by Schilling's estimate, there are about 350 Medicaid health plans.

"But remember that two years ago the number was zero Medicaid plans publicly reporting," he adds.

The insurers that made the lists are the nation's top overall performers on a range of key clinical performance measures related to issues such as cancer, diabetes, asthma, heart disease, and immunizations, says the NCQA. The organization further points out: "Of the top 10 Medicaid plans, at least six are from states where Medicaid health plans earn reimbursement incentives if they deliver higher quality care — a compensation strategy called 'pay for performance' that is gaining widespread acceptance in health care. More than 80 pay-for-performance projects are currently under way and CMS, the nation's largest purchaser of health care, is among the most committed supporters of the strategy."

Adds NCQA President Margaret E. O'Kane: "These health plans provide daily proof that achieving excellence isn't a question of plan type or market or profit status — it's hard work and accountability."

Medicaid Top 10 (listed alphabetically)

  • BlueCross BlueShield of Western New York (N.Y.)
  • BlueShield of Northeastern New York (N.Y.)
  • Coordinated Health Partners, dba Blue CHiP (R.I.)
  • Excellus BlueCross BlueShield, Rochester Region (N.Y.)
  • HealthPlus of Michigan (Mich.)
  • Kaiser Foundation Health Plan of Hawaii (Hawaii)
  • M-CARE (Mich.)
  • Neighborhood Health Plan of Rhode Island (R.I.)
  • Priority Health (Mich.)
  • UPMC Health Plan (Pa.)

Medicare Top 10* (listed alphabetically)

  • Blue Cross and Blue Shield of Massachusetts (Mass.)
  • Capital Health Plan (Fla.)
  • Excellus BlueCross BlueShield, Rochester Region (N.Y.)
  • Fallon Community Health Plan (Mass.)
  • Harvard Pilgrim Health Care (Mass.)
  • HealthPartners (Minn.)
  • Kaiser Foundation Health Plan of Colorado (Colo.)
  • Kaiser Foundation Health Plan of the Mid-Atlantic (Md.)
  • Kaiser Foundation Health Plan of Hawaii (Hawaii)
  • Keystone Health Plan Central (Pa.)
  • Rochester Area Health Maintenance Organization (N.Y.)

*List includes 11 plans because some scoring differences were too small to draw distinctions.

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.