It’s not often that commercial insurers get a pat on the back, but a recent Government Accounting Office study that compared home infusion coverage for Medicare beneficiaries and commercial insurers comes pretty close. The GAO study examined the

extent of Medicare fee-for-service coverage for this therapy. It found that coverage depends on whether the beneficiary is homebound and on other factors related to the beneficiary’s condition and needs.

In particular, there was a distinct difference in how commercial insurers and Medicare cover this therapy.

Commercial insurers provided comprehensive coverage of home infusion therapy under network-based MA plans, which may provide benefits beyond those required under fee-for-service (FFS) Medicare.

Nationwide, nearly 1 of 5 MA beneficiaries has comprehensive coverage through an MA plan that offers home infusion therapy as a supplemental benefit.

Some homebound Medicare FFS beneficiaries receive comprehensive coverage of home infusion therapy, which includes drugs, equipment and supplies, and skilled nursing when needed.

On the other hand, for beneficiaries who are not homebound, Medicare FFS is limited to the necessary drugs, equipment, and supplies, excluding nursing services.

For nonhomebound beneficiaries, Medicare FFS is further limited: Infusion drugs may be covered for those enrolled in a prescription drug plan, but neither equipment and supplies, nor nursing services is covered. This group of people would need to obtain infusion therapy in a hospital, nursing home, or physician’s office to have all therapy components covered.

When it comes to utilization, the commercial insurers in the study report using standard industry practices to manage utilization and to ensure quality of care.

Specifically, most commercial insurers require that infusion providers submit patient information in advance to support a request for coverage and receive payment authorization.

Insurers also report that they review samples of claims after payment to determine if they were billed and paid appropriately. None stated that they have had significant problems with improper payments or quality for home infusion therapy services.

In addition, commercial insurers report taking various steps to ensure the quality of services delivered in the home, including developing a limited provider network of infusion pharmacies and home health agencies, requiring provider accreditation, coordinating care by providers, and monitoring patient complaints.

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.