Things keep rolling along nicely for UnitedHealth Group, and possibly for the rest of the managed care industry as well. UnitedHealth posted a 36 percent increase in net profit in the second quarter. Net income went to $809 million, compared to $596 million for the same period last year, according to the Wall Street Journal. As the first major health insurer to report earnings, UnitedHealth is often seen as a harbinger for the industry.... More on UnitedHealth. Not everyone's enamored of the nation's second biggest health insurer. Consumer groups, for instance, have turned thumbs down to a merger of UnitedHealth and PacfiCare Health Systems. The California Medical Association also has doubts. "The merger troubles us. It places Wall Street's demand for profits ahead of Main Street's interest in good health care," Jack Lewin, MD, CMA's president, tells the Associated Press.... Many Americans believe in the urban myth that the "medical industry is withholding the cure for cancer from the public in order to increase profits," according to a survey published in the journal Cancer. Twenty-seven percent surveyed described that statement as true.... A new version of the Academy of Managed Care Pharmacy's Format for Formulary Submissions is available through the organization's Web site. The new format provides further clarification to manufacturers of the needs of health system formulary decision makers. "What health systems need is the comparative analysis of the product and the attending economics in a format that can be manipulated to make it relevant to their patient populations," says Richard Fry, director of programs for the Foundation for Managed Care Pharmacy, which provides training in the proper application of the new format.... Association health plans got a boost and a belt recently. The House voted 263–165 on July 26 to allow AHPs, which enable trade associations to pool their members in order to purchase insurance across state lines. AHPs would be regulated by the feds. Legislation allowing AHPs has made it through the House before, but not the Senate. President Bush insists that AHPs would work by allowing small companies to skirt hundreds of state regulations and mandates currently in place. Consumer groups argue that people would lose the protections that state oversight affords. In addition, a report issued by Georgetown University on the day the House voted says that AHPs would make businesses more vulnerable to scams. Stay tuned.

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.