The consulting company PricewaterhouseCoopers, which prefers to call itself PwC now, placed caring for people with dual eligibility among its list of the top 10 health care industry issues in 2013. The people who qualify for both Medicaid and Medicare are considered to be the country’s sickest and poorest people, falling “through the cracks of two programs that were not designed to work together.”

PwC’s study “Top Health Industry Issues of 2013: Picking Up the Pace of Reform” says that $320 billion was spent on dually eligible people in 2011, accounting for 39 percent of total Medicaid and 31 percent of total Medicare spending.

The Centers for Medicare & Medicaid Services hopes that health insurers will help to manage the costs, and social media might be one of the tools. “Some duals may be receptive to using digital communication for diabetes maintenance, weight management, disease management, and chronic care programs,” the study states. PwC finds that such people “are more likely than other consumers to use social media for health care purposes (63 percent compared with 40 percent).”

Interest in using social media

Have you and a doctor, nurse, or other caregiver ever communicated in the following ways about a health question you had?

Dual eligibility

Other consumers




Text messages



Neither of the above



Source: “Top Health Industry Issues of 2013: Picking Up the Pace of Reform,” PricewaterhouseCoopers , January 2013

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.