Aetna is unveiling something it calls the Medicare Open Plan, targeted for employers who want to offer retirees age 65 or over a fee-for-service Medicare Advantage plan. If CMS approves, Aetna hopes to launch the plan in January 2007.... A consumer-directed effort by Tufts Health Plan hasn't planned out the way management had hoped. Tufts is canceling its three-year joint venture with Destiny Health, a CDHP provider, because of a failure to meet enrollment goals. The plan, called Liberty, gained about 10,000 members since its launch in September 2003.... Medicaid managed care is making "outroads" in Colorado. Citing low payment rates, Colorado Access, the only private Medicaid HMO left in the state, plans to end its contract with Colorado in August. It has been a bumpy road for the program all along. In 2004, four HMOs sued the state for alleging underpaying. Colorado paid millions to settle and those four HMOs left the program. Now Colorado Access is leaving. Its CEO, Don Hall, says there just isn't enough money to be made.... People with unhealthy lifestyles should pay more for insurance, according a poll taken by the Wall Street Journal and Harris Interactive. An online survey of 2,325 adults in the United States found that 53 percent of respondents are fine with the idea of charging smokers and overweight people more. In 2003, 37 percent liked the idea when asked the same question. Could be a societal switch, something to think about on your cigarette break — way, way off in the corner of the parking lot there.

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.