Usually, health care costs rise when the economy recovers from a recession, even during a relatively slow recovery such as the present one. The deep recession that began in late 2007 officially ended in June 2009, but health care costs have remained relatively flat, according to the Kaiser Family Foundation. (See http://bit.ly/uRtlMi.) In the second quarter of 2009, 156 million nonelderly patients with private insurance made physician office visits. In the second quarter of 2011, that number fell to 129 million, a decline of 17 percent.

Kaiser notes that factors other than the recession and pace of recovery might be in play. For instance, the share of workers with at least a $1,000 deductible grew from 18 percent in 2008 to 31 percent in 2011.

Insurers profited last year because they raised premiums in expectation of rising utilization. Yet the long-term effects for clinician executives charged with managing the care of populations are somewhat murky. “In some cases people may be foregoing unnecessary care, meaning that health costs are reduced with little or no effect on health,” says the Kaiser survey. “In other cases people are likely cutting back on necessary care, potentially endangering patients’ longer term health and leading to higher costs over time.”

Quarterly trends in U.S. office visits, 2000–2011

Quarterly trends in U.S. office visits, 2000–2011

Note: These seasonally adjusted estimates have a 95 percent confidence interval of 4 percent. Produced by the Stanford University Program on Prevention Outcomes and Practices with the assistance of the IMS Institute for Healthcare Informatics.

Source: “The Economy and Medical Care,” Kaiser Family Foundation, Nov. 15, 2011.

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.