Reflecting the continuing foundering economy, membership rolls at nine major managed care companies continue to decline. In particular, WellPoint reported membership declines in its commercial risk business, according to the “2010 Managed Care Industry Report” from the KPMG Healthcare & Pharmaceutical Institute. The other eight companies are Aetna, Amerigroup, Coventry, Health Net, Health Spring, Humana, Kaiser, and United.

The report points out that 50 percent of the members at Aetna, United, and WellPoint are in nonrisk plans in which employers are directly responsible for health care costs. As health care costs continue to increase, large employers will continue the shift to nonrisk plans to better control future costs, says James Davenport, audit partner and health care practice leader for KPMG’s Minneapolis market.

Membership growth is expected to be slow for the industry in 2010, but acquisitions could increase growth rates for some companies. As enrollment is tied to employment levels, membership levels may increase if the employment situation improves.

“When 2014 arrives and the exchanges come online, we’ll probably see another change in the membership mix — to the tune of 34 million people. Companies are going to have to ask now, ‘Here’s what membership looks like today, but we know there’s a lot of change coming. Where do we want to be in the market when 2014 arrives?’” says Davenport.

Change in membership (millions)

Source: KPMG Healthcare & Pharmaceutical Institute, 2010 Managed Care Industry Report

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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.