Medicare Advantage seems to be the coverage of choice for low-income beneficiaries, according to a study by America’s Health Insurance Plans, the industry lobbying group. AHIP crunched data collected by the Centers for Medicare & Medicaid Services’ Medicare Current Beneficiary Survey to find that “64 percent of all minority (nonwhite) beneficiaries enrolled in Medicare Advantage in 2010 had incomes of $20,000 or less; 64 percent of African-American and 82 percent of Hispanic Medicare Advantage beneficiaries had incomes of $20,000 or less.

In addition, 58 percent of Asian-American beneficiaries enrolled in Medicare Advantage had incomes of $20,000 or less; 29 percent had incomes between $10,001 and $20,000, and 30 percent had incomes of $10,000 or less, the study states.

Just 39 percent of European-American Medicare Advantage enrollees had incomes of $20,000 or less.

The findings are not all that surprising. “We have been doing this survey for years and the findings from this survey are consistent with what we have seen previously,” says AHIP spokesman Robert Zirkelbach. The findings reinforce that insurers have wisely used resources in trying to be more attuned to cultural and ethnic barriers to getting care, says Zirkelbach. “Health plans are doing those things today — developing disease management and care coordination programs, providing decision support tools, addressing disparities in care, and much more.”

The study, “Low-Income & Minority Beneficiaries in Medicare Advantage Plans, 2010,” also looks at what it calls “active choosers” who, as the term implies, can choose between Medicare Advantage, Medigap, or fee-for-service Medicare. “Of low-income active choosers with incomes between $10,001 and $20,000 46 percent were enrolled in Medicare Advantage plans; 23 percent purchased Medigap policies; and 31 percent were covered by Medicare alone.”

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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.