Good news for employers can be found in a study by Hewitt Associates that reports that health insurance costs increased by 9.2 percent this year. That's the first single-digit increase since 2000. The report contained not-so-good news for employees. Their contributions to health care premiums increased 65 percent, from $877 per individual in 2002 to $1,444 this year.... Humana has agreed to pay $40 million (as well as an additional $18 million in legal fees to the plaintiffs) in a settlement of a class-action lawsuit filed by more than 700,000 physicians. The suit says that Humana delayed or denied payment of claims for medical services rendered by the doctors. Humana is the latest of the 10 health insurers named in the suit to reach a settlement.... Do as I say, not as I do? Medical malpractice claims paid by insurers and hospitals on behalf of doctors in their employ must be reported to the National Practitioner Data Bank. Now, however, a report by the Office of Inspector General says that between 1997 and 2004, agencies under the Department of Health and Human Services failed to report 474 instances in which they paid medical malpractice claims. HHS Inspector General Daniel Levinson sums up the problem by noting that "underreporting of the department's own medical malpractice cases lessens the usefulness of the National Practitioner Data Bank and undermines departmental efforts to regulate private and public sector compliance." Indeed.

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.