Barring a sudden economic downturn or a major international crisis, managed care reform legislation is likely to dominate Congress in the precious few weeks between summer recess and Election Day.

The American Association of Health Plans has joined the fray, warning of extreme economic consequences if four major aspects of reform legislation become law. AAHP released a Barents Group/KPMG Peat Marwick study that analyzed not specific bills, but provisions — some or all of which are part of each of the major reform proposals in Washington. The report suggests that if you think this year's relatively small premium increases were cause for concern, you haven't seen anything yet.

The study found premiums would rise between:

  • 2.7 and 8.6 percent if health plans are exposed to greater malpractice liability
  • 2.2 and 6.9 percent if utilization review is deemed to be a medical decision
  • 4.1 and 6.1 percent if plans are prohibited from determining medical necessity
  • 6.6 and 8.6 percent if plans are required to allow any willing provider — "willingness" means the provider agrees to go along with the rules of the health plan — to give care

When all of these factors are taken together into a worst-case scenario, the result could be a premium hike of more than 30 percent. Barents derived its estimates from Congressional Budget Office projections.

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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.