Steven Peskin MDThree times during the past month a friend has asked for advice regarding his/her personal health care or that of a family member out of frustration and concern stemming from not receiving clear communication/information about the health problem(s). This scenario is all too common.

Paul E. Terry, PhD

The Affordable Care Act codified the worksite wellness exemption to the federal medical underwriting provisions in the group health plan market. This means companies are allowed to use an “outcomes-based” incentive model that provides financial rewards for those who satisfy a prescribed health standard such as a BMI of less than 30 or who meet a “reasonable alternative standard” or obtain a waiver from their physician. What some see as “rewards” others view as penalties or surcharges and, given the absence of evidence to confirm the role of such incentives in actually improving population health, the new provisions have unleashed a debate about the ethics and putative effectiveness of the new provisions.

Al Lewis

When an employer group shifts from one health plan to another, why not allow them to take their claims data to the next health plan? That way, the new plan would gain immediate knowledge of the specific disease burden faced by its new members and be able to act accordingly vis-à-vis care management programs and other interventions. As it stands now, the new plan would have to wait many months and even then would lack the history that the earlier plan no longer needs. And when the new plan “finds out" about a member's condition, it might be due to a claim for an event that could have been prevented had the carrier had access to the earlier data.

Here’s how the system would work. When a group signs up with a carrier, it could reserve the right to have its data transferred if it changes carriers. Obviously, it wouldn’t be able to “see” its own patient-identified data any more than it does now, but the data would accompany the change of carriers.

Life is change. We here at Managed Care are breathing new life into our website by changing its look, but not only the look. Sure, it is more streamlined and easier on the eyes, but the change that excites us is in the content, which is richer and more interactive.

Steven R. Peskin, MD, MBA, FACP

As we move Managed Care into the blogosphere, my curiosity was arosed about the number of active English language blogs. As with many internet related statistics, I found a wide range of estimates from 152 million (BlogPulse, February 2011) to 450 million — Hat Trick Associates. I unsuccessfully spent a bit of time searching for the number of healthcare specific blogs.

Suffice to say, a surfeit of blogs. Since we seek value in managed care, I pose the question, "What is the relative value of blogs?" — reading blog posts, contributing to blogs, operating blogs.

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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.