Insurers are increasingly targeting the individual insurance market — traditionally viewed as static — as a potential growth opportunity, according to a study from the Center for Studying Health System Change (HSC). In the past, the individual market has attracted older, sicker people. This is adverse selection, and in response, insurers tend to avoid people with the greatest health needs or to set premiums higher to reflect those individuals’ expected medical use.

That’s changing, according to the report. The economic downturn has caused a decline in the proportion of people with employer-sponsored coverage. Also, a sizeable population of younger, healthier people is forgoing insurance. Insurance officials also think that subsidies to buy insurance under the proposed health care reform might also have an effect.

“If enacted, current health reform proposals, which envision a larger role for the individual market under a sharply different regulatory framework, would likely supersede insurers’ current strategies,” says HSC President Paul B. Ginsburg, PhD, coauthor of the study.

As insurers shift their focus, they are turning to states with favorable regulatory environments (the individual insurance market is regulated at the state level), offering lower-cost products and using marketing strategies that make it easier for consumers to shop for coverage.

The HSC study reviewed the market conditions in 12 communities in which the individual market tended to be dominated by mainstream insurers, typically a Blue Cross–Blue Shield plan. Places with less state regulation exhibited more competition: Ohio, South Carolina, Indiana, and Arkansas.

Reform proposals under debate include subsidies for low- and moderate-income people to buy insurance, creation of insurance exchanges, and much stricter regulation of the individual market.

Proposed regulatory changes include a mandate for individuals to be covered, guaranteed-issue requirements, a ban on medical underwriting, use of modified community rating, and products standardized by actuarial value.

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.