No sooner had the quality rankings of health plans in the nation, as measured by the National Committee for Quality Assurance (in partnership with U.S. News & World Report), been released then it was pointed out that most of the top performers werenot-for-profit insurers. Of course, making that argument was the lobbying group, the Alliance for Advancing Nonprofit Healthcare, whose name says it all.

Still, the Alliance made some valid points, including:

  • Commercial plans — 70 percent of the top 50 are not for profit.
  • Medicare HMOs — 80 percent of the top 25 are not for profit.
  • Medicaid HMOs — 76 percent of the top 25 are not for profit.

"We encourage researchers both within and outside these organizations to perform their own analyses of possible correlations between quality and ownership status," says Bruce McPherson, the executive director.

One such study, published in the journal Health Services Research in August, suggests that health plans that contract with tightly organized physician practice groups score higher on preventive health care indicators measured by the NCQA and the Consumer Assessment of Healthcare Providers and Systems surveys. Of course, the health plans that tend to contract with tightly organized physicians, or employ them outright, are not-for-profit plans.

Charles M. Cutler, MD, the head of national quality management at Aetna, told us in October that every approach has its strengths — and weaknesses. "The staff- and group-model health plans provide an infrastructure such as patient registries and electronic medical records that supports better performance on HEDIS measures," Cutler said. "On the other hand, they have much narrower networks and they have practice bureaucracies that some patients find daunting."

Top five commercial plans:

  • Harvard Pilgrim Health Care (Maine, Mass.)
  • Tufts Associated Health Maintenance Organization (Mass., N.H., R.I.)
  • Harvard Pilgrim Health Care of New England (N.H.)
  • Blue Cross and Blue Shield of Massachusetts
  • Capital District Physicians' Health Plan (N.Y.)

Top five Medicare plans:

  • Preferred Care (N.Y.)
  • Harvard Pilgrim Health Care (Mass.)
  • Tufts Associated Health Maintenance Organization (Mass.)
  • Capital Health Plan (Fla.)
  • Kaiser Foundation Health Plan of Southern California (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.