Congressional Republicans, eager to please in an election year, seem willing to support a pharmacy benefit in Medicare. That, combined with the drug industry's new willingness to negotiate on the issue, has heightened speculation that a benefit plan will pass this year.... Foundation Health has consolidated its commercial plans into two divisions — East and West. The idea is to create operating and administrative efficiencies.... Highmark is trying a risk-adjustment payment system for cardiologists, ophthalmologists, and orthopedists in Pennsylvania. The three are its highest-cost specialties, in terms of Medicare claims dollars.... Kaiser Permanente dropped a recruiting tactic that offered 10-percent bonus pay to physicians in the early years of their practices. Though it had been alleged the bonus was tantamount to age discrimination, Kaiser says it ended the practice because it is no longer needed.... Healtheon/WebMD and HNC Software have hit on a plan that will allow physicians to file claims over the Internet for free with any payer that participates in the service.
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.
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?
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.
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.