In an ideal world, payers and providers would be on the same page when it comes to ANSI X12, version 5010 compliance and ICD-10 code readiness. But a recent survey conducted by the Healthcare Information and Management Systems Society (HIMSS) indicates that most providers will not be ready to test their electronic health information systems by Jan. 1, 2011. Only 38 percent report that they have an actual system and 35 percent report that they have no plans to implement one.

On Jan. 1, 2012, standards for electronic health care transactions change from ANSI version 4010/4010A1 to version 5010. These electronic health care transactions include functions like claims, eligibility inquiries, and remittance. Unlike the current version 4010/4010A1, version 5010 accommodates the ICD-10 codes, and must be in place before the changeover to ICD-10.

It’s unlikely that providers will be able to make up ground to meet the January deadline, according to the survey. Providers also report difficulties in finding knowledgeable staff and vendors who are ready for the transition.

In June 2010, providers reported only limited progress on 5010 compliance
Do not expect to have a 5010 project started before the end of 2010 33%
Haven’t even started an impact assessment, the first step in preparing for 5010 40%
Have an approved budget 21%
Started contacting vendors 15%
Have yet to consider 5010 planning 35%
Plan to upgrade existing system 74%
Plan to replace existing system 9%
Source: HIMSS 5010/ICD-10 Industry Readiness Survey

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.