About 15 million new enrollees are expected to flood Medicaid in 2014, a massive 30 percent increase. Health plans have been preparing for some time, because states, already burdened by the program, are looking to managed care to help control costs. (http://bit.ly/gPqf95)

Provider data management will be crucial to making managed Medicaid work, says Michael Siegel, MD, corporate medical director at Molina Healthcare, a health plan with Medicare and Medicaid plans in 16 states. For one thing, it will pinpoint doctors who need help.

“For instance, if we see that a physician has a high ER usage, we can work directly with this physician to identify the causes and encourage specific members to get preventive care,” says Siegel. “Ultimately, this allows us to create a better medical home.”

A challenge of this type of data collection may be presenting the data in a clear format that allows providers to act accordingly, he adds.

Matthew Haddad, JD, president of Medservant Technologies, a physician data management vendor, says that “for those MCO medical and pharmacy directors charged with ongoing provider quality assurance, compliance monitoring, claims fraud detection, and a million other details, the influx of new patients and providers, compounded by the addition of ever-changing Medicaid rules and regulations, can become simply overwhelming.”

The new federal rules bump eligibility for the program to include adults with incomes of up to 133 percent of the federal poverty level, a move that could bring in younger and healthier adults.

Arnold W. Cohen, MD, chairman of the department of OB/GYN at Albert Einstein Medical Center in Philadelphia, says that in such an environment, “Data availability in a format that is user friendly is necessary for any medical director to determine how to manage care or to decrease costs. If we perceive something to be a problem, such as the number of ultrasounds per pregnancy, there is no way to convince doctors that there really is a problem unless you have data to confirm the problem.”

This, of course, is yet another function that plans can elect to do either in-house or through a vendor. “At Molina, we collect the data in-house,” says Siegel. “The advantage of contracting this service is that it would allow us to free up analytical resources for other purposes. The advantage of doing it in-house is that we’re able to verify the credibility of the results quickly and efficiently.”

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.