People who will be uninsured for any part of 2008 will spend about $30 billion in out-of-pocket costs and receive about $56 billion in uncompensated care. The payer who picks up most of the tab? The federal government, not private insurers, pays about 75 percent or $42.9 billion, according to researchers at George Mason University and the Urban Institute.

And while it is thought that private insurers adjust for uncompensated care by shifting costs, the researchers found that this isn’t the case.

The study, published in Health Affairs, notes that cost shifting as a result of uncompensated care has a “very small impact on private insurance premiums.”

Jack Hadley, PhD, a professor and senior health services researcher in the department of Health Administration and Policy at George Mason and lead author, estimates that $14.1 billion could be financed by shifting costs.

The researchers say that total private health insurance expenditures for 2008 will be $829.9 billion, but the amount potentially associated with cost shifting represents at most 1.7 percent of private health insurance costs.

“Covering the uninsured will likely lead to a significant increase in demand for both drugs and coverage by managed care programs,” says Hadley. “Since the currently uninsured tend to have lower incomes, they should be more likely to seek coverage through lower cost insurance products, i.e., managed care. Another possibility is that the expanded insurance coverage would be through public programs, especially Medicaid. Based on past experience, expanded Medicaid coverage is also likely to increase the demand for managed care plans.”

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.