Alan Adler, MD, MS
Independence Blue Cross, Philadelphia, Pa.
Craig Lipkin, MS
Independence Blue Cross, Philadelphia, Pa.
Lisa Cooper, MSW
Independence Blue Cross, Philadelphia, Pa.
Michael Agolino, MSW
Independence Blue Cross, Philadelphia, Pa.
Violet Jones, RN
Independence Blue Cross, Philadelphia, Pa.

Introduction

The goal of this study was to determine the effectiveness of having an Independence Blue Cross (IBC) health plan social worker meet with patients who were members in IBC’s special needs program (SNP) prior to discharge during an acute hospital admission. SNP members have dual eligibility — i.e., they have both Medicare and Medicaid medical benefits. These patients have many non-medical factors that influence their use of services. These include poverty, lack of caregivers at home, difficult home environment, difficulty filling prescriptions (mail unsafe), transportation difficulties, and illiteracy.

The social worker’s role is to serve as a transition coach, as discussed in detail below. Such coaches aren’t direct caregivers and so can handle larger caseloads. The main objective was to increase enrollment in IBC’s case management program for this population. Some secondary objectives were to reduce hospital readmissions and emergency room (ER) visits. Other objectives included increasing primary care physician (PCP) and specialist visits and follow-up contact rates. This was a non-randomized study implemented at an urban academic hospital. A social worker was assigned to talk to the eligible patients with admissions from September 2007 to May 2008. The social worker made rounds at the hospital approximately two days per week, and interviewed half of all eligible patients. The social work intervention was designed to educate patients about the case management program available to them at IBC and about as other benefits, such as subsidized public transportation. In addition, the social worker focused on self-management skills, making sure the members scheduled follow-up appointments with their PCP, filled and adhered to prescriptions, and remained receptive to follow-up calls from social services. An information sheet with contact information and reminders was given to the member.

Author correspondence:
Alan Adler, MD, MS
Senior Medical Director
Independence Blue Cross
1901 Market St., 31st floor
Philadelphia, PA 19103
E-mail: alan.adler@ibx.com

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.