John Marcille

John Marcille

Don’t believe it until you see it. Our cover story on mental health parity by Contributing Editor Martin Sipkoff reports that we are at a turning point. The focus is mainly on what legislators will do, but Washington, D.C., is famous for good ideas that never became law.

As Martin notes, there’s a House version that practically no one likes and a Senate version that almost everyone likes. He artfully outlines the pros and cons of each and shows just what employers specifically, and the nation’s health care apparatus generally, would gain in outcomes and savings. He notes that although pharmacy costs did actually go up, “Aetna Behavioral Health demonstrated a total cost savings of $136 per member per month… compared to members who were not enrolled.” This experience and other data show that health plans should welcome the push for parity.

Now, on the matter of the New York attorney general’s attack on plans’ reimbursement of UCR charges. This is not the problem it is made out to be. Health plans just need to restate the formula as a percentage of what the plan pays to an in-network physician or other provider for that service, not tying it to an arbitrary UCR calculation. The plan should always pay outsiders less than it pays network providers, and that difference should be made clear. Why continue a system that is confusing and seems unfair?

Payers should have no trouble with this. Moreover, full transparency here will alert patients to exactly how much the non-network provider is charging. They can easily see why a network provider, in most cases as good as or better than the out-of-network provider, is to be preferred. They can also see that some providers are gouging the patient who has no health plan to negotiate prices for him and the patient who forgoes that advantage by going out of network.

Plans would have been better off, and will be better off, with real transparency.

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.