More on the pay-for-performance push. MedVantage, a consulting company, says that more such programs (42 percent) are now aimed at specialty care. But physicians are wary. "There are a lot of established markers for quality care in our specialty, but often even in those, there is disagreement," Ronald Vender, MD, a partner at the Gastroenterology Center of Connecticut, tells the Wall Street Journal.... The nation's HMOs operated on a slim profit margin in the first three months of 2004, according to Weiss Ratings. This, despite the fact that they reported $3 billion in profit, representing a $742 million increase over the $2.3 billion the companies earned for the same period in 2003. "Although the industry has enjoyed an increase in revenues by raising premiums, insurers have also had to deal with the rising cost of medical care as a result of more open networks, an aging population, expensive medical advances, and an inefficient health care system," says Melissa Gannon, Weiss's vice president.... Health coverage is not a factor in determining the level of care children ages four months to 35 months receive in the U.S., according to a study in December issue of Pediatrics. Neither is race, ethnicity, or income. Then why, according to the study, is one-third of that population not getting the preventive care it needs? "I think, frankly, [providers] are not doing the kind of job they should be doing," Barry Zuckerman, MD, chief of pediatrics at Boston Medical Center, tells the Boston Herald.... CMS has selected the 26 regions of the country where Medicare Advantage will offer PPOs. It also unveiled last month the 34 regions where private drug coverage will be offered to beneficiaries. The reaction of health plan officials, who wanted more regions, was mixed. Karen Ignagni, president and CEO of America's Health Insurance Plans, appreciated that CMS "really worked hard" to come up with the plan. Alissa Fox, policy director for Blue Cross and Blue Shield Association, said that "This makes it more difficult for the Blues plans."
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.