Membership at most of the top (by enrollment) eight health insurers — Aetna, Cigna, Health Care Services (a Blue Cross Blue Shield company), Health Net, Humana, Kaiser Permanente, UnitedHealth Group, and WellPoint — continued to fall through the third quarter of 2009, according to research by Debra A. Donahue, vice president for market analytics and online products at Mark Farrah Associates, a provider of marketing data. Between September 2008 and September 2009, top plans, which included both fully-insured and administrative-services–only lines of business, saw an aggregate decline of 1.7 million members. These eight health companies cover nearly 60 percent of the total insured population in the United States.

Blame the weakened economy. “Employers aren’t hiring or offering additional coverage, and are laying off staff. The declining commercial numbers aren’t being fully offset by Medicare and Medicaid,” Donahue says.

Although the graph shows growth at Aetna, all of the growth came in the first quarter of 2009. “They’ve been slowly declining for the last two quarters. There is no growth for the majority of these plans,” says Donahue.

He continues: “To get membership numbers back up, premiums will have to come down. The way to do that is through more generic drug use and reducing pharmacy and medical costs. All these plans are focusing on ways to reduce costs.”

Source: Health Insurer Insights, Mark Farrah Associates

Fewer enrollees, 9/08–9/09

Change in top health plans’ total membership

“To get these membership numbers back up, premiums will have to come down,” says Debra A. Donahue, a VP at Mark Farrah Associates.

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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.