Washington Initiatives

The Medicare+Choice program is getting out of the gate rather slowly. At press time, the Health Care Financing Administration had received only two applications from groups wanting to establish provider-service organizations and one from a prospective preferred-provider organization — and none at all from insurers offering medical savings accounts.

What's the problem? According to HCFA spokesman Peter Askenaz, it's too early to make any judgments. The regulations were released June 26, Askenaz notes, and it takes time for health care organizations to get the paperwork together to submit to HCFA. Don't rule out possible regulation confusion — after all, the 833-page regulation document isn't exactly light reading. And finally, the decision to become a risk contractor is not one that "organizations should enter into lightly," says Askenaz. "It represents a substantial financial commitment."

Still another factor may be that interested parties are taking a hard look at the less-than-profitable experience some Medicare HMOs have experienced in certain markets, particularly in rural areas.

Currently, Medicare allows beneficiaries to enroll in health maintenance organizations. Medicare+Choice, also called Medicare Part C and a product of the Balanced Budget Act, is designed to provide beneficiaries with the option to enroll in other types of arrangements, such as PSOs and MSAs. Time is running out on the MSA option, however; beneficiaries who want to join must sign up by next month.

After so much hoopla about PSOs, their future is very much up in the air. According to Robert Berenson, director of HCFA's Center for Health Plans and Providers, physician-run organizations may be reluctant to become risk contractors when payment rates do not necessarily promise to support such a bold move.

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.