All the focus on accountable care organizations might be overkill, considering that participation is voluntary. Health plans face other deadlines, however. For instance, the clock is running for insurers to plan and prepare for transition to the ICD-10 coding system. The compliance date is Oct. 1, 2013, and the preparation involves a lot of work: There are approximately 13,000 ICD-9-CM codes; ICD-10-CM will have 68,000.

“Medical directors need to ensure their medical policies have been reviewed and updated as warranted for ICD-10,” says Jim Daley, director of risk and compliance information at Blue Cross Blue Shield of South Carolina and a nationally recognized expert on ICD-10. “Depending on the extent that specific codes are referenced in policies and on the number of policies, the policy review itself can consume hundreds or even thousands of hours. Even if specific codes aren’t mentioned in the policies, medical directors need to ensure that the policies will continue to operate as intended under the new code set.”

Expect IT challenges galore, says Daley. “IT applications may contain logic that enacts the medical policies, and that logic must be reviewed and updated for ICD-10. This will require the knowledge of medical directors to properly map logic to the new codes.”

ICD-10 (the International Statistical Classification of Diseases and Related Health Problems 10th Revision) is the latest code set from the World Health Organization to categorize diseases. It is overseen in this country by the Department of Health and Human Services. Periodically, ICD goes through major revisions. In between, there is continuous updating of codes, as well as the addition of a handful of new ones each year. ICD-10 represents a scope of change not attempted since 1946 with ICD-6.

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.