Not much will change in Medicare Advantage this year and that’s news, given some of the dire forecasts leveled about the program. “Despite reductions in payments enacted in the ACA [Affordable Care Act], and concerns about the effects of these reductions for plans and beneficiaries, the Medicare Advantage marketplace remains robust in 2013, with little change in the number of plans offered and relatively modest increases in average premiums,” says the report “Medicare Advantage 2013 Spotlight: Plan Availability and Premiums” from the Kaiser Family Foundation (http://kff.org/medicare/upload/8388.pdf). “…On average, beneficiaries will be able to choose from among 20 plans, the same as in 2012. On average, beneficiaries will be able to choose from among 22 plans in urban areas and 13 plans in rural areas.... Almost all of the plans offered in 2012 will be available in 2013, so enrollees will be able to stay in the same plan if they choose.”

Special needs addressed

The number of special needs plans (SNPs) is expected to increase this year, the study says. “Of the 214 chronic care SNPs in 2013, 23 percent are focused on beneficiaries with diabetes, another 36 percent are focused on beneficiaries with diabetes and some form of cardiovascular disease and/or congestive heart failure, and 27 percent are focused on beneficiaries with specific lung conditions.”

However, the number of SNPs specifically for persons with dual eligibility will decrease. “Interpreting the change is complicated by the fact that states have been pursuing pilot demonstrations in 2012 to better align Medicare and Medicaid spending for dual eligibles.”

Number of MA plans by plan type

Medicare beneficiaries with access to one or more MA plans in 2013

Distribution of SNPs by plan type

Source: “Medicare Advantage 2013 Spotlight: Plan Availability and Premiums,” Kaiser Family Foundation, December 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.