With the Obama administration moving quickly to take the reins at Medicare, officials recalled a draft of the 2009 Medicare Advantage and Part D call letter, signaling that changes are probable.

“Some of the Medicare advocates as well as folks on the Hill like California Democrat Pete Stark have called on the Obama administration to rescind it and put their own stamp on it,” says Paul Precht, director of policy and communications at the Medicare Rights Center.

“We want to ensure that benefits provided by Medicare Advantage plans provide adequate financial protection, are easier to understand, and are transparent for the consumer.”

Some cost-sharing techniques that can prove a nasty surprise for members are likely to be at the top of the list of upcoming changes, which would be put in place for 2010.

“We’ve seen plans with out-of-pocket limits that exclude certain services,” adds Precht. “Sometimes we find out those services are Part B drugs, which includes chemotherapy. We would want language to say more definitely that that type of arrangement is not acceptable.”

The letter also provoked a quick cheer from Pete Stark, the chairman of the House Ways and Means Health Subcommittee and a longtime critic of Medicare Advantage.

“This letter would have locked in another year of lax Bush-era guidelines for private insurers in Medicare, and I am pleased that the Obama administration rescinded this letter,” he said in a statement.

Medicare Advantage plans should not have long to wait to find out exactly what the new administration has in mind.

“We recognize that MA organizations and PDP sponsors need to have 2010 guidance available in order to prepare their bids by the statutory deadline, and therefore [we] will post a draft reflecting any changes resulting from a review of the current draft as soon as possible,” CMS said.

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.