MANAGED CARE February 1997. ©1997 Stezzi Communications

The AMA has withdrawn its backing of employer-sponsored health insurance in favor of promoting individually owned policies. Its House of Delegates voted in December to support individually purchased insurance as "preferred method."insurance as the "preferred method" to cover employees.

The AMA has historically supported employer-provided insurance and just three years ago backed a federal bill mandating that all employers purchase health insurance for their workers. Now, to fund private insurance, the AMA has called for tax changes that would give employees the same breaks that employers now receive. A majority of delegates supported the change, but some raised the point that many doctor-run networks are trying to sell their services to large employers. The AMA contends that individuals controlling their health care options would improve opportunities for physician networks and improve the doctor-patient relationship.

Many large companies oppose any changes in tax breaks, but in the long run employers would probably prefer to quit the health benefit business, says Sean Sullivan, president of the National Business Coalition on Health. "Separating the people who use care from those who pay for it is economically a bad idea," says Sullivan.

Health plans are concerned that administrative costs for individual policies would send premiums through the roof. Plus, employers have more clout than individuals in holding HMOs accountable for providing high-quality care, says Bo Piela, spokesman for the Massachusetts Association of HMOs.

Humana will cut 700 to 900 jobs nationwide to slow the tide of receding earnings, the company has announced.

Humana posted a net loss of $10 million during the first nine months of 1996.

The layoff, accounting for about 5 percent of Humana's 18,000 employees, will be largely in administrative positions, the company says.

Humana isn't the only plan to trim staff. Healthsource, which operates HMOs in 16 states, has said it would lay off 32 employees, and HealthCare USA in Florida has dropped 22 of 125 staffers.

— Paul Wynn

The federal government estimates that about 10.5 million Americans under 65 purchased their own health insurance in 1994. Buying individual health insurance is most common in the Mountain states, among self-employed people and farm workers.

Percentage of population aged 18 to 64 having individual health insurance in selected industries

Source: U.S. GENERAL ACCOUNTING OFFICE REPORT: PRIVATE HEALTH INSURANCE

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.