Higher out-of-pocket costs reduce utilization, according to a report by PricewaterhouseCoopers. The report (http://pwc.to/vYdbaE), based on a survey of 1,000 people, collected consumers’ perspectives on what sort of health care services they prefer and what they think of the changing health care landscape.

“Higher deductibles and co-pays have suppressed utilization,” the report states. The plan design showing the greatest growth rate is the high-deductible plan. “The percentage of employers whose most-enrolled plan was high deductible went from 13 percent in 2010 to 17 percent in 2011.” Unfortunately, “high-deductible health plan (HDHP) enrollees cut back on preventive services such as childhood vaccinations, mammography, and cancer screenings.” In addition, “a higher percentage of HDHP enrollees didn’t fill or refill prescriptions.”

It wasn’t just enrollees in HDHPs who cut back on utilization. “Regardless of health plan, 46 percent of consumers surveyed … said they have deferred care in the past year because of cost.” In the meantime, the report notes that the “identities of providers and insurers are blurring as they team up to harness data across the spectrum of care and benefit from new payment models.”

Health insurers have committed more than $2 billion in the last year to acquire or align with physician groups, with certain deals making headlines, including Highmark’s investment in West Penn Allegheny Health System and Optum’s purchase of a 2,300-doctor physician group. Optum is a subsidiary of UnitedHealth Group.

PwC says that 72 percent of consumers want integrated care models, feeling that such models will lower costs and improve quality.

“If these provider-insurer partnerships are able to achieve results similar to recent Medicaid-provider partnerships, the impact could be substantial,” 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.