The retail prices of the 50 pharmaceutical products most prescribed to the elderly increased almost three times the rate of inflation last year, says a Families USA study. Prices for the medications jumped 7.8 percent, compared to the 2.8 percent rise (energy costs excluded) in the Consumer Price Index.... The New York State Department of Insurance leveled stiff penalities against Aetna U.S. Healthcare and United Healthcare over the plans' failure to inform members properly about how to appeal claim denials. Aetna was fined $1.5 million; United $1 million, and both have promised to reexamine claims that had been denied between mid-1994 and late 2001.... Poor publicity resulting from stories about denied appeals and other high-profile mistakes made by managed care organizations has led the American Association of Health Plans to hire the William Morris talent agency to help improve the industry's image in TV and movies. The AAHP wants to counter the negative image of the industry that's become part of popular culture, though organization officials doubt that there will be an overnight turnaround.... One good way to start such a public relations effort may be to get the word out about a new program by Blue Shield of California. On July 8, the insurer launched a health plan for Mexican migrant workers and their families. Jim Arriola, head of cross-border operations for Blue Shield, tells the Contra Costa Times that the plan will "provide better access to care for a segment of our society that is encountering a lot of challenges and difficulties in the health care system."

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.