Of the 3.3 million low-income beneficiaries who have Medicare Part D coverage, 65 percent (2.2 million) will have to choose a new plan in 2010 or face paying a premium if they decide to remain in their current plan, according to a recent Henry J. Kaiser Family Foundation report, “Part D Plan Availability in 2010 and Key Changes Since 2006.” CMS will reassign the remaining low-income subsidy (LIS) enrollees.

The report says that the number of benchmark PDPs — those that charge no monthly premium to low-income subsidy enrollees — has decreased. Compared to 2006, there will be 102 fewer plans available in 2010 — a 25 percent decrease. LIS plan availability will decline in 18 of 34 regions between 2009 and 2010, while 13 regions will gain plans. The largest increase in LIS plan availability will occur in Arizona, Louisiana, Missouri, and Nevada.

The number of private organizations that provide benchmark plans has fluctuated over the last five years, according to the report.

In 2006, Humana, UnitedHealth, Wellcare, and WellPoint qualified to offer LIS plans in nearly all regions, but in 2010 Humana will have LIS plans in only three regions and WellPoint will have these plans in only nine regions. The report says that Humana, Universal American, CVS Caremark, UnitedHealth, Wellcare, and WellPoint all had benchmark plans in 23 or more of the 34 regions in 2006, but only Universal American and UnitedHealth will qualify with benchmark plans in as many as 23 regions in 2010.

Source: Georgetown/NORC analysis of CMS PDP landscape source files 2009–2010, for the Kaiser Family Foundation.

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.