Employer-sponsored health coverage will remain the dominant model of insurance, according to a study by IMS Payer Solutions. About 44 million more Americans will have health coverage by 2020, thanks to the Affordable Care Act — if it is found to be constitutional — and 25 million of them will be in insurance exchanges.

The study questions data, particularly those collected by the Medical Expenditure Panel Survey (MEPS), that have been interpreted to mean that private insurance might fade. IMS says that with limited access to private sector data, health services researchers have relied on analysis of public data to inform public policy recommendations, but to effectively advance health care reform a deeper understanding of the privately insured population will be critical to successfully addressing cost and growth trends.

To take just one example, IMS says that outpatient and inpatient services amount to 59 and 20 percent of total spending, respectively. The MEPS, which is sponsored by the Agency for Healthcare Research and Quality, says it’s 39 and 43 percent, respectively. The influx of patients into private insurance will mean that clinical executives will need to gain a better understanding of how members with cancer, chronic conditions, and autoimmune diseases — the high-cost members — use health care services.

Insurance enrollment in millions, real and projected

Insurance enrollment in millions, real and projected

Health care expenditures in billions, real and projected

Health care expenditures in billions, real and projected

Note: The IMS survey is based on a review claims for 10 million privately insured people under age 65 that took place between Jan. 1, 2009 and Dec. 31, 2010.

Source: “Healthcare Spending Among Privately Insured Individuals Under Age 65,” IMS Institute for Healthcare Informatics, February 2012

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.