Purchasers are increasingly requiring health plans to focus on the quality of health care delivered to consumers, according to the National Business Coalition, which says that more health plans are reducing barriers to essential treatments. For example, 27 percent of plans are waiving copayments for diabetes drugs and 33 percent have reduced copayments… Low Medicare and Medicaid payments to hospitals and physicians lead to significantly higher insurance costs for consumers and employers, according to a study by Milliman. The study found that annual health care spending for an average family of four is $1,788 higher than it would be if Medicare, Medicaid, and private insurers paid hospitals and physicians at similar rates. Government payers tend to underpay hospitals and physicians. This creates a payment gap that privately insured employers and consumers must close through cost shifting, which is the difference between actual payment rates and average payment rates… Nineteen percent of employees are willing to pay higher premiums in order to keep deductibles and copayments lower and more predictable, says a survey from Watson Wyatt. Last year, though, 38 percent chose the higher premiums. Some workers are taking actions that could lead to higher costs in the future. For example, 17 percent reported that they avoided a recommended doctor’s visit this year to save costs. Similarly, 17 percent did not fill a prescription or skipped doses of prescribed medications, an increase from 13 percent in 2007.

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.