A Kaiser Family Foundation report examining the cost implications of giving Medicare recipients coverage options has found that there are "no obvious 'right' choices for beneficiaries." The report, Paying for Choice: The Cost Implications of Health Plan Options for People on Medicare, estimates a range of spending for three different prototype beneficiaries in eight markets.

"Spending is often lower in Medicare+Choice plans, but this is not always the case," the authors found. The question of whether an M+C plan will be available to beneficiaries is a complicating factor. And M+C — as is the case with all options — is subject to geographic variation. For instance, a frail, 80-year-old woman who chooses the least expensive medigap plan would spend $6,376 in Manchester, N.H., but $9,520 if she lived in Miami. On the other hand, she could spend as little as $1,342 for the cheapest M+C plan in Miami, but as much as $7,082 for the lowest-cost M+C option in Seattle. The other markets examined in the study are Oakland, Calif., Minneapolis, Chicago, Dodge City, Kan., and Baltimore.

M+C often least expensive choice

Estimates for a 50-year-old man with disabilities
  Medigap M+C No supplemental insurance Range of costs across all sources
Premium range $432–14,412 $0–1,194 $0 $0–14,412
Nonpremium range $7,445–11,058 $6,010–11,049 $12,335–12,380 $7,445–12,380
Total range of costs $8,541–21,857 $6,010–11,049 $12,335–12,380 $6,010–21,857
Estimates for a healthy 65-year-old woman
  Medigap M+C No supplemental insurance Range of costs across all sources
Premium range $407–8,074 $0–1,194 $0 $0–8,074
Nonpremium range $1,587–2,808 $1,342–8,134 $10,546–10,673 $1,342–10,673
Total range of costs $2,683–9,661 $1,342–8,962 $10,546–10,673 $1,342–12,482
Estimates for a frail 80-year-old woman
  Medigap M+C No supplemental insurance Range of costs across all sources
Premium range $528–8,074 $0–1,194 $0 $0–8,074
Nonpremium range $4,408–8,532 $1,342–8,134 $10,546–10,673 $1,342–10,673
Total range of costs $6,376–12,482 $1,342–8,962 $10,546–10,673 $1,342–12,482

SOURCE: PAYING FOR CHOICE: THE COST IMPLICATIONS OF HEALTH PLAN OPTIONS FOR PEOPLE ON MEDICARE, KAISER FAMILY FOUNDATION, MENLO PARK, CALIF.

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.