MANAGED CARE January 1997. ©1997 Stezzi Communications

Democratic state Rep. Patricia Gray has introduced legislation to make Texas the fifth state to assure women direct access to Ob/Gyns and the right to designate Ob/Gyns as their primary care physicians.Gray, who represents part of Galveston County, objects to gatekeeper policies that require women to see family doctors or internists before they can visit Ob/Gyns. "Also, most plans' rules prohibit women from seeing their Ob/Gyns more than once a year," she says. "That's not adequate access."

Under House Bill 180, Ob/Gyns could choose to make themselves available as primary care physicians. Women not selecting Ob/Gyns for this role would nevertheless have access to Ob/Gyns without a referral. And no copayments could be charged for Ob/Gyn visits unless they were also charged for other health care services.

Gray also introduced a bill, No. 99, that requires health plans to cover 48-hour post-delivery maternity stays. This year, she says, she intends to sponsor a bill that would prohibit treating mastectomies as outpatient procedures.

House Bill 180 is supported by the Texas Women's Coalition for Physician Choice and the Texas chapter of the American College of Obstetricians and Gynecologists.

Texas' HMO association doesn't necessarily oppose the bill, but is concerned that Ob/Gyns are not properly trained, like generalists, to treat the whole body. Family physician groups oppose the measure.

Laws in Alabama, Maryland, Maine and Oregon require insurers to permit eligible Ob/Gyns to contract as primary care physicians and also give patients direct access to an Ob/-Gyn. Fifteen other states have similar, but less sweeping measures on the books.

Jeanne Shaheen, New Hamp-shire's first Democratic governor in 14 years, made health care issues a central theme in her campaign to win a four-way governor's race. Having won with 57 percent of the vote, she's expected to evaluate the state's pending Medicaid waiver, which would usher about 50,000 Medicaid beneficiaries into managed care plans. Currently, the state has a voluntary HMO enrollment program. It applied for the waiver in June and hopes to get word from the Health Care Financing Administration by February or March.

Shaheen does not oppose the mandatory plan, but she wants the program monitored to ensure that managed care organizations are reducing costs without jeopardizing quality.

In her campaign platform, Shaheen also included an "HMO Consumers' Bill of Rights" that sought to prohibit financial incentives for HMO providers to deny or delay care, require an appeals process for enrollees, establish quality standards and require reasonable access to physicians.

The Illinois Medical Society has scrutinized 1995 data from 37 HMOs and found that, on average, $0.85 of every revenue dollar was spent on medical care. The data, provided by the state's insurance department, also revealed that some plans spent 40 cents or more of every dollar on paper work.

The study found that out-of-state HMOs that cover Illinois residents had the highest and lowest medical expense ratios. Cigna Healthcare of St. Louis spent $0.47 per dollar on health care, while John Deere Family Health Plan of Iowa tallied a positively philanthropic $1.49.

— Paul Wynn

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.