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.
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?
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.
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.