Inhaling steroid medications might not be necessary, according to a study that finds no difference in outcomes for people with asthma who took the drugs each day or only when symptoms occurred. “The discovery that these two courses of treatment do not differ significantly could eventually change the way doctors and patients manage asthma, providing an option that is easier to follow and possibly less expensive,” says William Calhoun, MD, of the University of Texas Medical Branch at Galveston, and lead author of the study that appears in the September 12 issue of the Journal of the American Medical Association.... The 16 million new beneficiaries expected to flood Medicaid rolls in 2014 as a result of the Affordable Care Act might have a tough time finding doctors, according to a study in Health Affairs. Physicians in many parts of the country are wary of accepting new Medicaid patients because of what they perceive as unfair pay — Medicare pays much better. Another development: State participation in the expansion of Medicaid is optional under the Supreme Court’s ruling on the ACA, and some governors are leaning against it.... Physicians are in such high demand that they should be wary of just shooting their resume and C.V. out willy-nilly, because they could be inundated with responses, says physician recruiter Jim Stone of the Medicus Firm. Stone tells that “Just shotgunning their C.V. out can result in a lot of extra work on their part.” A doctor posting on the job board of the National Association of Physician Recruiters (Stone is president-elect) might receive 200 to 500 responses within 48 hours. Nice to be wanted.... Insurers and employers cannot deny coverage or benefits to transgender people, according to a ruling by the Department of Health and Human Services. Citing Section 1557 of the ACA, the ruling says that the “sex discrimination prohibition extends to claims of discrimination based on gender identity or failure to conform to stereotypical notions of masculinity or femininity....” However, in further clarification, the HHS says that this does not mean that insurers have to cover gender transformation surgery.

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.