A baseline report issued by the National Business Coalition on Health called the "eValue8 Cornerstone Report: Measuring the Success of America's Health Plans" finds that price transparency is still in its infancy and that there is a wide variation in plan performance when it comes to promoting transparency, care improvement, and information technology. The variation suggests that improvement is achievable and needed.

The report says that insurers are better at providing quality information about hospitals than about physicians, as only 6 percent of health plans report standard physician performance measures to members for clinical conditions (e.g., diabetes or cardiovascular disease). In contrast, almost 30 percent of plans provide reports to members about hospital quality in such areas as heart attacks and pneumonia.

"Managed care organizations are moving away from medical approvals ... and moving towards a more global role, such as transparency — measuring the performance of the physicians in their network and sharing that with their members," says Dennis White, senior vice president of the National Business Coalition on Health.

"The challenge for medical directors is getting measurements in place, which means measuring physician performance and sharing it with members and also providing feedback and bonuses to physicians as a reward."

Health plans are in a position to "connect the dots," says White. "Plans know when prescriptions are filled by the patient; plans know what lab tests are done. The physicians could know, but their practices are not structured to notice if a lab result is missing. We encourage plans to provide that information and use the data that is at their command."

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.