Before enrolling in a consumer-directed health plan (CDHP), people may want to take stock of their financial assets. Relatively few uninsured households have enough financial assets to cover the cost sharing in CDHPs that are tied to a health savings account (HSA), according to a recent study conducted by Kaiser Family Foundation researchers and published in Health Affairs. An HSA allows beneficiaries to pay for current health expenses and to save for future qualified medical and retiree health expenses on a tax-free basis.

While premiums for these plans are relatively low, families with low-to-moderate income levels don’t have the financial assets to cover the deductible should a member get sick. The new study examined the asset levels of households with two or more uninsured members in 2004 and compared it to the range of cost-?sharing features in HSA-qualified health plans.

Assets are an important consideration because these families may not have adequate income to pay the potentially high cost sharing under these policies and would have to dip into any savings they might have to pay their bills.

“Although lower premiums may increase the ability of the uninsured to buy some coverage, high out-of-pocket liability may leave families exposed to costs that they cannot meet,” write the authors, Kaiser researchers Paul Jacobs and Gary Claxton.

Kirk Pion, executive director of consumer initiatives at Health Care Services Corp., which operates the Blue Cross and Blue Shield plans in Illinois, New Mexico, Oklahoma, and Texas, says this problem can often be addressed during discussions about benefit design between the employer and insurer.

“Employers are funding part of the HSA account, so they can offset the member’s exposure and try to fund the HSA appropriately,” Pion says.

As a result, HSAs can have a rich preventive benefits package that includes annual physical examinations, immunizations, and mammograms, for example, that are covered 100 percent, Pion says.

“Medical directors and pharmacy directors can provide their clinical expertise to the Internal Revenue Service when it comes to what should and what shouldn’t be covered,” says Pion. “Insurers are having some difficulty trying to figure out the IRS’s guidelines about taxable benefits. The guidelines are vague. The government needs some clinical guidance about what constitutes preventive care,” Pion says.

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.