March 2016

It’s survival of the biggest because of IT, data collection, and other factors. But the health insurance market is also full of nooks, crannies, and niches that are friendly to small fry and newcomers.

Jan Greene

The trade association has been hit by defections, deficits, and staff departures. Can Marilyn Tavenner, AHIP’s new CEO, get it back on course?

Richard Mark Kirkner

CMS veteran Marilyn Tavenner oversaw a rocky debut for HealthCare.gov. Now she’s at the helm of AHIP as some major members need to be coaxed back into the fold.

Interview by Richard Mark Kirkner

A desire for more control and the ACA seem to be fueling the long-term trend.

Peter Wehrwein

Coverage kicks in if someone has a major illness like a heart attack or stroke. And because critical illness policies are a voluntary benefit, they help employers cut costs to avoid the Cadillac tax on health benefits.

Joseph Burns



Departments
Legislation & Regulation

Free-market advocates question state say-so over major hospital projects. They have a strange bedfellow.

Richard Mark Kirkner
ACO Update

ACOs are providers while MA plans are insurers. Still, CMS’s Next Generation ACOs have a familiar look and feel.

Robert Calandra
Viewpoint
The hope is that reducing the per capita cost of health care by combining these stakeholder roles should remove volume as an incentive and excess charges as a temptation.
Richard Stefanacci, DO
Plan Watch

UnitedHealthcare, Aetna, and Humana all lose money, but Cigna’s CFO says that’s just the price for getting started in a new market.

Frank Diamond
Cancer Watch

Cancer patients talking to doctors doesn’t work very well: Half of all symptoms go unreported. Computerized systems and email prompts may do a better job.

Peter Wehrwein
Tomorrow’s Medicine

Alirocumab, evolocumab, and sebelipase alfa further fuel the discussion about just how to go about covering exciting, but costly, high-priced agents.

Thomas Morrow, MD
Snapshot

Percent of U.S. health care spending by 7 core health consumer segments

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.