Patrick Mullen

We'll hear a lot about state-level managed care reform this year. Many states are considering bills that, in several respects, mirror aspects of consumer protection measures now under debate in Washington, D.C. Maryland and Virginia could be the next states to strengthen the rights of patients who appeal health coverage denials. And in Maryland, legislators may soon consider whether to increase the roles of physicians in the appeals process.

This session, the Maryland General Assembly is expected to consider a proposal giving the state insurance commissioner authority to resolve coverage disputes after a plan's internal appeals procedure had run its course. The commissioner would be allowed to consult third-party physicians before making a determination. The bill would apply only to HMOs — not to other types of managed care plans. A similar proposal failed to pass last year.

Maryland's bill could also contain language designed to allow nurse practitioners to contract directly with HMOs. That would overrule a decision by the insurance commissioner barring such an arrangement. Commissioner Steven Larsen ruled in November that while advanced-care nurses can perform many of the same functions as doctors, HMOs must contract with a physician, who then may hire a nurse practitioner to provide primary care. He cited state law that requires patient care to be under physician management.

Nurse practitioners counter that another state law prohibits HMOs from discriminating against providers who practice as their licenses allow. Under Medicare and Medicaid rules, nurse practitioners can operate independent of physician supervision.

In Virginia, Health Commissioner Randolph Gordon is trying to revise the state's appeals process by moving it from the insurance department to the health department. Currently, HMOs send cases for appeal to an independent medical expert hired by the plans. Under Gordon's proposal, the health department would hear the appeal, removing any appearance of a conflict of interest.

Wisconsin Bills Aim at Denials Of Coverage

Two bills introduced in the Wisconsin Legislature would expand the rights of patients when dealing with physicians and plans. The bills, which are similar, were introduced by Rep. Frank Urban, a physician, and Sen. Carol Roessler, both Republicans.

Under the proposals, prior authorization would not be needed for emergency services if a "prudent lay person" would conclude that the emergency was serious enough to require a trip to the hospital. Health plans that deny claims would be required give patients written explanations of denials of coverage, along with instructions for pursuing appeals.

Plans would have to offer a point-of-service or similar option so members could see non-plan physicians, and would also have to provide ways for new members to continue to see their current physicians — even those not in the plan — as long as they like.

Plans would have to reveal details of physician payment and incentives, coverage, premiums, deductibles and prior payment authorization, while guaranteeing public access to enrollee-satisfaction statistics.

Finally, the state insurance commissioner would appoint a task force on standards for certifying health plans. Current regulations focus on plans' financial status, not on questions concerning provider panels or patient care issues. The task force would expand the certification review process to include these issues.

Health plans say many of the bills' provisions are already state law, and that further regulation would drive up health care costs. The state medical society supports the measures.

Pa. Would Bar Inducements To Withhold Care

Managed care gag rules limiting the information physicians can give patients about coverage and treatment options would be outlawed under provisions of a bill approved last month by the Pennsylvania Senate's Public Health and Welfare Committee.

The measure also would bar plans from using financial incentives to discourage doctors from rendering care they deem medically necessary, or to reward them for giving less than medically necessary care.

All members would be able to continue to see their physicians for two months after the physician left a plan, and women who switched plans in mid-pregnancy could see the same physician through post-partum care even if the doctor wasn't in the plan.

A provision that would have given physicians final say over health plans when ordering or rejecting medical procedures was dropped, though language guaranteeing coverage of services if a physician determines them to be medically necessary remains in a bill making its way through the House.

N.Y. Pharmacists Seek Limited Prescribing Rights

The Pharmacists Society of the State of New York wants to expand the scope of practice of pharmacists so they can prescribe drugs in certain situations. The group says change is needed if pharmacists are to prosper under managed care. Independent pharmacies in particular have been hit hard as managed plans have directed patients to chain drug stores and mail order prescription fulfillment services.

The society supports a bill that is expected to go before the legislature this year that would allow pharmacists — using a written protocol from a doctor — to adjust dosages, order lab tests and prescribe medications for routine ailments. Pharmacists say the change would benefit physicians by freeing them to spend more time with other patients. That argument that has failed to sway the Medical Society of the State of New York, which opposes the measure.

N.C. Physicians Fight For-Profit Takeovers

A group of North Carolina physicians last month formed an organization they say will fight to reclaim control of care delivery from for-profit managed care companies.

The group's news conference announcing formation of the North Carolina Ad Hoc Committee to Defend Health Care was timed to coincide with the Journal of the American Medical Association's publication of a call to action by Massachusetts physicians who have formed a similar group.

The North Carolina group, which says it is acting in the interests of patients and health care professionals, calls on the state to place a moratorium on for-profit takeovers of hospitals, insurance plans, HMOs, physician practices and other health care entities.

42% in California Have Gripes With Health Plans

More than four out of ten Californians with health insurance had problems with their health plans in the last year, according to a survey commissioned by Gov. Pete Wilson's task force on reforming managed care.

Researchers at the University of California at Berkeley and the Field Research Corp. surveyed 1,200 people, then extrapolated their results to project that 6.7 million residents of the state had some kind of beef with their plans. Since only 3 percent of those with private health insurance in California have fee-for-service coverage, the results pertain overwhelmingly to managed care plans.

Of these, 1.6 million experienced delays or denials in medical treatment, received inappropriate care or had trouble getting a referral to a specialist. Still, 76 percent of respondents said they were satisfied or very satisfied with their plans; 10 percent were dissatisfied or very dissatisfied. Members of group- and staff-model HMOs registered highest satisfaction levels, while members of IPA-model HMOs were least happy with their plans.

Patrick Mullen

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.