Health insurers are experiencing a shift in the sources of revenue, with factors like the downturn in the economy and the changing demographics of members playing a major role, according to a report from Mark Farrah Associates, an aggregator and publisher of health plan market data. The report says U.S. health plan revenues totaled $370.8 billion for 2009, up from $346.1 billion (7.2 percent) in 2008. But comprehensive commercial coverage as a percentage of total revenue has fallen from 59 percent in 2006 to 51 percent in 2009, the last year data were available.

So where is this revenue change coming from? Medicare and Medicaid, according to the report. Managed Medicare now accounts for 21 percent of health plan total revenues, up 16 percent from 2006. Revenue from state Medicaid plans also grew as a percentage of total revenue from 10 percent in 2006 to 14 percent in 2009, a consequence of current economic conditions and a result of more states moving toward managed care to insure low-income residents.

Health plans’ sources of revenue, 2009

Commercial 50.8%
Managed Medicare 21.1%
Managed Medicaid 13.6%
Federal Employees Health Benefit Plan 7.3%
Dental only 2.1%
Medicare supplement 2.0%
Vision only 0.4%
Other health 2.6%

Source: Mark Farrah Associates. “Health Plans See Revenue Shift Away From Commercial,” May 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.