Joseph Burns
Contributing Editor

As they prepare for health reform, many health plans are investing in primary care. WellPoint bought the Medicaid managed care plan CareMore, for example. UnitedHealthcare bought Monarch, a large physician group practice. Those health plans that do not acquire a large provider group are developing virtual networks, says Charles Kennedy, CEO of Aetna Accountable Care Solutions.

“Aetna is creating new accountable care networks based on collaboration with existing delivery systems in which we have a variety of relationships. That means we will have what’s called a virtual network. But basically all health plans are doing the same thing: becoming more vertically integrated because that’s what the accountable care organization model calls for,” he says.

“Here’s how I define a virtual network: In most settings today, you have hospitals and physicians who generally don’t have a business, financial, or administrative relationship other than that they are both caring for the same patient. Similarly, a primary care physician and an oncologist may not be in the same group practice but they still need to work together to take care of the same patient.

“For these situations, a virtual network is needed to get those two providers, who are separate entities from a business perspective, to integrate for clinical and financial performance. That’s the essence of virtual integration.

“Of course, communication is needed between these providers, but communication is an elemental component in part because physicians currently communicate in a rudimentary way through paper and fax,” he adds. “If they’re lucky, they have some kind of electronic exchange of information. But for a virtual network, we will need to be able to establish a common understanding of what each patient needs so that everyone understands the patient, the disease state, and how that patient is being managed. Once you have that common understanding, you can start to work as a team.”

A new financial model

Kennedy adds that, “Once you have the ability to communicate about the patient in this way, you can have a financial model that rewards the physician for improved performance. That leads to some form of gainsharing that we will see in the different models of ACOs. That allows the incentives to work as they should because we have the technology to communicate.”

Charles Kennedy

Health Plan 2020


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.