Private insurers paid $272 billion in hospital charges in 2005, according to “National Hospital Bill: Growth Trends and 2005 Update on the Most Expensive Conditions by Payer,” a report issued by the Agency for Healthcare Research and Quality. The total 2005 hospital bill, which is adjusted for inflation, was $874 billion and accounted for 39 million hospital stays. The average yearly rate of increase in the national hospital bill over the last several years was 4.5 percent. At this rate, researchers estimate that the annual national hospital bill may reach $1 trillion in 2008.... Health Level Seven, America’s Health Insurance Plans, and the Blue Cross & Blue Shield Association announced that they have agreed to create a collaborative process to maintain portability standards for personal health records. The group contends that the more stakeholders involved in developing and approving portability standards, the more easily plan members will be able to move their personal health data when coverage changes.... More than half (53 percent) of health care payers surveyed in “Financial Transparency: Health Care Payer Strategies and Execution, 2007–2009” planned no additional investment in transparency initiatives in 2008. Instead, health care payers will assess the effectiveness and return on current transparency initiatives to identify best-practice industry models. Key initiatives include creating electronic access to information; improving data and information processes; consolidating data sets to produce accurate, reliable data sources; and adopting standards.

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.