Privacy proposals will be one of the most prevalent — though not the most hotly debated — issues related to health coverage in state houses this year, according to a survey by the Health Insurance Association of America. Prescription drug coverage, prompt-payment mandates, and so-called "legislation by body part" aren't far behind.of America. Prescription drug coverage, prompt-payment mandates, and "legislation by body part" aren't far behind.

The push for privacy legislation will stem from Congress's passage of the Gramm-Leach-Bliley Act, which gives health insurers a broad mandate for managing and protecting medical information, but leaves it up to states to hammer out the how-to. States' need to respond will result in legislation in almost every capitol this year.

Programs to help elderly and low-income people pay for prescription drugs, which passed in 24 states last year, will also have high visibility again this year. This may be the most explosive issue at the state level; pharmaceutical companies will watch carefully as states craft discount programs (see item about Maine at right).

A hot button at the state level last year — liability — will be less important this year. Thirty-two states debated liability last year, but only one bill passed. Liability measures have been introduced in eight states this year and may be crafted in as many as 12 more, but HIAA says the advent of external-review laws — passed so far by 40 states and the District of Columbia — has, for now, cooled passion for liability laws.

As for coverage mandates, HIAA expects the more popular proposals this year to include coverage for clinical trials, infertility, and mental health parity, among others.

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.