From February 2010 through February 2011, total Medicare Advantage plan enrollment was up 7 percent. That’s significantly higher than the 5.8 percent rate from the same time frame one year earlier. The Centers for Medicare & Medicaid Services lists MA plan enrollment at 12,164,793 (as of Feb. 1, 2011), with a gain of 790,702 net new members from February 2010 to February 2011. That’s about 26 percent of the 46.4 million people who are eligible for Medicare.

Debra A. Donahue, a vice president for market analysis and online products at Mark Farrah & Associates, says, “In a nutshell, more Medicare Advantage members means greater oversight of network physicians [stricter policies and procedures], additional outcomes tracking [CMS uses quality metrics in its pay scale to plans and reports this data back to potential members], and increased need for geriatric and other specialty providers within networks.”

The more MA members a health plan has, the greater the importance of the roles of the medical director and pharmacy director, according to Donahue. “We are already seeing partnerships develop among top health plans in the Medicare marketplace with pharmaceutical manufacturers, and the medical and pharmacy directors play a pivotal role in managing these relationships.”

A recent report from Mark Farrah & Associates, which provides health plans with market data and analysis, says that there was some concern among health plans that the shorter open enrollment period and cancellation of private-fee-for-service (PFFS) plans as of January 2011 would have a negative impact on enrollment, but this was not the case.

Donahue adds that the Medicare Advantage enrollment growth rate was beginning to slow down during the 2009 open enrollment season (for effective dates in January 2010), “so it was good news for these plans to see the overall rate improving.”

She says a 7 percent growth rate is manageable for most plans and probably wouldn’t tax an insurer’s infrastructure drastically. “Some of that growth may be the result of demographics, but it also suggests that the managed Medicare model may be gaining increased acceptability by seniors,” says Donahue. That’s good news for insurers that place emphasis on this type of coverage.

The report says that from February 2010 to February 2011 the top five health plans in terms of MA growth (plans with more than 250,000 members) were WellPoint (17.7 percent), Humana (9.9 percent), UnitedHealth (8.6 percent), Highmark (6.6 percent), and Kaiser (5.4 percent). UnitedHealth and Humana together hold 33.4 percent of the MA plan market, up 0.7 percent from last year.

According to the report, there’s also been a slight drop in the number of health plans with more than 250,000 MA members.

For example, in February 2009 there were 10 plans with more than 250,000 members. That number dropped to eight in February 2010, and as of February 2011, there were only seven. Universal American, one of the eight plans with more than 250,000 MA members in 2010, dropped to 175,035 members as of February 2011.

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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.

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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.