Small and mid-size health insurance plans are evenly split on whether to participate in accountable care organizations, according to a recent white paper.

Some regional insurers are “taking charge and forming private ACOs through alliances with regional health systems, individual practice associations, or physician groups,” says “Moving Forward With Reform: The Health Plan Pulse for 2012 and Beyond.” The paper was written by the consulting company Healthcare Technology Management Services (HTMS) for the Managed Care Executive Group, an association of regional and mid-sized health plans (http://bit.ly/xUM33A).

Of the 61 respondent health plans, 61 percent were not-for-profit while 39 percent were for-profit. The online survey was conducted last year.

“Despite the flurry of attention ACOs have received, however, the responding health plans were split — 47 percent said they were actively planning for ACO development, while a matching 47 percent responded that they were still trying to understand how this new model would fit into their organizations.”

Plans that are part of an integrated delivery system are most actively exploring the ACO path, the study says. Whether ACOs take off or not, respondents expect that more interaction with physicians and other providers will be part of their future.

“When given the opportunity to add or further describe strategic priorities for the upcoming year, a large number of survey participants mentioned partnerships with providers — much more than in previous years. This finding suggests that closer payer/provider relations may become a tactic for potential strategic advantage.”

The plans also look forward to the establishment of state health insurance exchanges, with 53 percent saying that they would help expand membership.

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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.

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.