Looking ahead to 2011, beneficiaries enrolled in all Medicare Advantage (MA) plans will find limits placed on their out-of-pocket expenses, and while that sounds like good news, for many MA plans, the limits are quite high. Previously, about half of all MA-PD (Medicare Advantage-Prescription Drug) plans offered some coverage in the drug coverage gap (the “doughnut hole”; see article on Page 36). Between 2011 and 2020, that gap will gradually be filled because of changes enacted in the Patient Protection and Affordable Care Act.

A recent “Medicare Advantage 2011 Data Spotlight” report from the Henry J. Kaiser Family Foundation says that about half of all plans will have limits of $3,400 or less, about the same share as in 2010 (48 percent in 2010 and 51 percent in 2011), but fewer plans will have limits of $2,500 or less (5 percent versus 9 percent) — and considerably more will have higher limits.

Of the MA plans currently available, HMOs will likely have lower limits set on out-of-pocket spending than other plan types.

The report says that 59 percent of Medicare HMOs will have a limit of $3,400 or less, as compared to 41 percent of regional PPOs and 23 percent of private fee-for-service (PFFS) plans. PFFS plans are more likely than other plan types to have limits over $5,000 in 2011.

Nearly half (46 percent) will have limits between $5,001 and $6,700.

Share of MA plans with limits on out-of-pocket spending, 2010-2011 / Share of MA plans by limits on out-of-pocket spending, by plan type, 2010-2011

NOTE: Excludes SNPs (special needs plans), employer-sponsored group plans, demonstrations, HCPPs, PACE plans, MSAs, and plans for special populations (e.g., Mennonites). Excludes plans sanctioned by CMS. Percentages are unweighted by enrollment. Totals may not add to 100% beause of rounding.

Source for both: Gold M, Jacobson G, Damico A, Neuman T. Medicare Advantage 2011 Data Spotlight, October 2010

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.