In what’s being called one of the first instances of a group using the Affordable Care Act to contest an insurer’s benefit package, a women’s advocacy group says that a beneficiary should not have to pay for a dependent’s pregnancy costs. The Wall Street Journal on June 4 reports, “The complaints are rooted in a health law provision requiring employers to allow workers to keep dependents up to 26 years old” on coverage plans.... The Supreme Court ruled last year that states could opt out of Medicaid expansion, and so far 14 have done so, according to a report in the June issue of Health Affairs. This saves the government about $8.4 billion a year, but ensures that 3.6 million more people will be without insurance. The states not participating, though, are likely to see an increase in spending in the short run because they’ll have to spend more on uncompensated care.... CareFirst BlueCross BlueShield’s foray into the world of patient-centered medical homes has paid off handsomely. The health plan, with 3.4 million covered lives in Maryland, Washington, D.C., and northern Virginia, reports that it saved $98 million last year with its patient-centered medical home. It saved $38 million in 2011. Some experts worry that medical home savings will dwindle over time as doctors run out of obviously wasteful methods to eliminate. Most of CareFirst’s savings came from lower drug spending, less use of emergency departments, and fewer hospital admissions.... COPD hits women hardest, a report by the American Lung Association reaffirms. Women are 37% more likely to have COPD then men. About 7 million women are known to suffer from the disease, and millions more have it but have not been diagnosed.... We spend $200 billion each year, mostly in unneeded hospitalizations and doctor visits, thanks to the improper use of prescription drugs, according to a study by IMS Health’s Institute for Healthcare Informatics. The study, released June 19, says too many patients take the incorrect drug or dose. There is often inadequate oversight when patients are taking more than one medication. The study also cites the misuse of antibiotics. The authors say that financial incentives included in the ACA for better care coordination may help reduce the amount of waste.... Men are much more likely to develop health care related infections than are women, according to a study in the Journal of General Internal Medicine. Men have a 60% higher risk of developing bloodstream and surgical site infections.

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.