WellPoint and Cigna are turning heads in the financial world. Cigna's second-quarter earnings rose 73 percent from the same period last year to $720 million as its earnings kept well ahead of medical costs thanks to higher premiums and lower operating costs, reports the Wall Street Journal. Meanwhile, the newspaper says that WellPoint's earnings are expected to rise 15 percent a year for the next five years.... California health insurers have marked Jan. 1, 2007 on their calendars. That's when the state is expected to move more than a half-million recipients of Medicaid (known as Medi-Cal in that state) into managed care. Gov. Arnold Schwarzenegger sees the move as an important part of curbing soaring costs. Critics counter that only mass confusion will ensue, and the sought-after savings will not appear.... Transparency is key, according to a plan by a coalition of 52 employers that outlines how they want PBMs to conduct business. PBMs would have to give to their clients the drug company rebates that now often go to the PBMs, according to the Wall Street Journal. In addition, PBMs would have to disclose the acquisition costs for retail and mail-order drugs. So far, only three PBMs have agreed to the terms outlined by the employer coalition, HR Policy Association. Those PBMs: Aetna Pharmacy Management, MedImpact Healthcare Systems, and Walgreens Health Initiatives.... "Preventive care services" means different things to different health insurers, says a recent report in the Wall Street Journal. The article quotes Andrew Baskin, Aetna's senior medical director, as blaming the problem on a lack of a universally accepted standards. "There is no industrywide definition here," says Baskin, "so each insurer has the ability to define preventive services for [itself]." Patients can have a tough time trying to figure out, for instance, just what drugs are covered by an insurer as a preventive treatment.

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.