Health insurers have to cover eight preventive health care services at no cost under the Affordable Care Act, and they are not thrilled, according to the plans’ lobbying group. “Broadening the scope of mandated preventive services that go beyond or conflict with the current evidence-based guidelines will increase the cost of coverage for individuals, families, and employers,” says Robert Zirkelbach, a spokesman for the advocacy group America’s Health Insurance Plans. He warns that there could be a corresponding increase in costs.

The Institute of Medicine (IOM) identified diseases and conditions that are more common or more serious in women than in men or for which women experience different outcomes or benefit from different interventions. The IOM report suggested full coverage for the following additional services:

  • Screening for gestational diabetes
  • Human papillomavirus (HPV) testing as part of cervical cancer screening for women over age 30
  • Counseling on sexually transmitted infections
  • Counseling and screening for HIV
  • Reproductive health counseling, including contraception education and prevention of unintended pregnancies
  • Lactation counseling and equipment to promote breast feeding
  • Screening and counseling to detect and prevent domestic and other interpersonal violence
  • Yearly well-woman preventive care visits to obtain recommended preventive services

Linda Rosenstock, dean of the School of Public Health at the University of California–Los Angeles, is the chairwoman of the IOM’s committee of experts that made the recommendation in a report titled “Clinical Preventive Services for Women: Closing the Gaps.” Rosenstock says that the eight services “are necessary to support women’s optimal health and well-being. Each recommendation stands on a foundation of evidence supporting its effectiveness.”

Insurers contend that they are already covering preventive services based on evidence-based guidelines from independent third-party groups. “Health plans have prioritized prevention and encourage patients to get recommended preventive care,” says Zirkelbach. “Current coverage of preventive services is based on the recommendations put forth by independent, expert organizations such as the Advisory Committee on Immunization Practices (ACIP) and the U.S. Preventive Services Task Force (USPTF).”

The report, however, says current guidelines on preventive services contain gaps when it comes to women’s needs. Because they need to use more preventive care than men on average. Women also face higher out-of-pocket costs, the report says.

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.