Blue Shield of California members are changing utilization patterns as a result of hospital tiering, say company officials. The company is making further changes in its Network Choice program. David Joyner, Blue Shield's senior vice president for network management, tells the Contra Costa Times that "there's some evidence that people are starting to think about their decisions in a different way."

Network Choice, launched in April 2002, stipulates that the 1 million Blue Shield members enrolled through all but the largest employers have to choose between "choice" (no charge) and "affiliated" ($100–$300 daily copayment) hospitals.

For large employers, the program will be offered next year as an option to reduce premiums.

Of the 307 hospitals that contract with Blue Shield of California, 84 fall into the low-cost category, the Contra Costa Times notes. The program tiers hospitals according to cost and some generally recognized quality measures.

With its disclosure that savings are being seen (though no numbers were offered), Blue Shield announced that it was further revising Network Choice by adding more quality measures. The total number of quality measures is now 14.

"It is also now taking into account a hospital's mix of patients, giving credit to hospitals that care for sicker patients," the Contra Costa Times reports. "In addition, Blue Shield has revised how it groups hospitals to compare their relative costs. Before, it divided California into only eight regions. Now, there are 32." Expect plenty more HMOs to launch tiered plans in the near future.

"I think we're going to see this coming out in most markets," predicts Brad Kimler, a health care consultant with Hewitt Associates. "Right now, most people really don't know what costs are." Under a tiered plan, they can take baby steps toward finding out.

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.