As reported in this magazine last month, HMO-bashing as a campaign topic seems to have lost some luster. For instance, not much is heard these days about a patient's bill of rights, which was supposed to make HMOs more legally accountable for denial-of-care decisions. Possibly this is because cost has so much overshadowed complaints about anything else.

Still, recent statements by Sen. Hillary Rodham Clinton suggest that health plans may not be able to fly under the radar until fall. And those who are looking for any excuse to bash HMOs will turn anything into a weapon, including a recent study pointing to healthy profits.

HMOs reported $6.98 billion in profits for the first six months of 2005, according to a report by Weiss Ratings. That is a $1.2 billion, or 21.2 percent, increase from the $5.76 billion earned during the same period in 2004.

"Despite a slowdown in earnings growth, industry profitability remains strong," says Melissa Gannon, vice president of Weiss. "With premium rate increases leveling off, insurers will look for more innovative cost control measures to remain competitive and financially secure."

But will they remain so secure that they won't be targets for politicians?

"HMO bashing is certainly a seasonal sport," says Peter R. Kongstvedt, MD, the senior executive at Accenture Health & Life Sciences Consulting. One of the reasons it's been out of season the last few years, he says, is that actual HMO enrollment has declined and those members who are still in HMOs are relatively satisfied.

"Now we have all these other products: PPOs, CDHPs, and others that hold sway," says Kongstvedt. "Also, a lot of the old-style HMO activities like referral authorizations, have declined as well."

Still. . . .

"But oh my, it's always an easy target," says Kongstvedt. "And when the political environment calls for some good old vilification, they make a convenient 'villain.' Never mind that the profits being reported from these various public companies have more non-HMO business than they do HMO business."

It's still early in the political season. 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.