According to researchers at the Centers for Disease Control and Prevention, rates of immunization for children remained below 70 percent from 1999 through 2002 in commercial managed care plans. The researchers analyzed the plans' HEDIS scores, publishing the results in the American Journal of Managed Care.

They found that the childhood immunization rate was significantly below the 80 percent target in Healthy People 2010, a set of national health objectives issued by the U.S. Department of Health and Human Services. Despite improved rates from 1999 to 2002 (65.7 percent to 67.9 percent), MCOs need to address specific problems.

For example, immunization rates varied significantly by the type of patient visit. Health plans with more well-child visits than sick-child visits had higher rates of immunization than plans with more sick-child visits than well-child visits. Researchers recommended that MCOs encourage providers to ask about current immunizations during every visit.

The American Academy of Pediatrics predicts that the increasing costs of vaccines, combined with low payments from insurance companies, will lead to under-immunization. It said that payers are not recognizing the full cost, which is not just the acquisition price of the vaccine but includes ordering, storage, inventory control, and spoilage.

Factors associated with higher immunization rates
NCQA accreditation status, yes vs. no +2.6%
Public reporting status vs. nonpublic reporting status +3.2%
Proportion of Pacific Islanders +0.6%
Proportion of African Americans -0.2%
Proportion of Hispanics -0.2%
Proportion of enrollees ages 25 months to 6 years who made visits to their primary care physician +0.2%
Enrollment size >= 120,000 vs. < 120,000 +2.2%
Years in business +0.3%
All significant at P<.05
Source: Bardenheier, B, et al. Am J of Man Care. 2007;13:193–200.

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.