John Marcille

Each month our Plan Watch column looks at some of the interesting things individual insurers are doing. This month we practically present an entire edition of Plan Watches.

One of our stories looks at how Harvard Pilgrim Health Care delivers such amazing HEDIS scores for cardiovascular care. Geisinger Health Plan comes front and center as we look at how it dismisses the old notion of trying to control physicians with another approach that’s much less fractious and, it seems, much more effective. Further on, Cigna unveils some of the findings from a study of 440,000 members that indicate that consumer-directed health plans foster better preventive medicine and save money to boot.

I am not forgetting other health plans that are also praised for their efforts in this issue, but are sort of in the background. For instance, there is a very complimentary mention of Aetna in the Harvard Pilgrim story. Let us also not forget the official Plan Watch in which Kaiser Permanente offers advice on how to keep physicians content.

These are all great examples of how resourceful health plans can be, but they are not why you started reading this issue. No, it was probably because you got a gander at our cover about million-dollar claims. That story by Contributing Editor Maureen Glabman highlights how plans with traditional levels of reinsurance can get into trouble, and describes other ways in which the megaclaim threat can be dealt with.

The story of managed care is in many respects a story of how health insurers and integrated systems discover inadequacies in the system and create socially acceptable and effective ways of fixing them. It’s true that managed care has had limited success in controlling costs, and megaclaims are an extreme example, but I shudder to think where we would be, cost- and outcomes-wise, if we still had an uncontrolled indemnity system.

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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.