The marriage of Medicaid and managed long-term care might require an ironclad “pre-nuptial” agreement, according to a Kaiser Family Foundation study. “Examining Medicaid Managed Long-Term Service and Support Programs: Key Issues to Consider” talks about states’ interest in farming out operations of Medicaid long-term services and support (MLTSS) to health insurance plans.

The study relies on literature and discussions in the spring and summer with federal and state officials, representatives of health insurance plans, consumer advocates, and providers. Some respondents worry that health plans “could accept low capitation payments but then fail to provide adequate services, particularly community-based services. Some interviewees are wary of the involvement of for-profit plans in the MLTSS programs.”

Most respondents want the plans’ responsibilities laid out in contracts that also mandate how results are to be reported and what the states will look at in determining performance.

“Plan representatives say they are particularly eager to understand states’ expectations, and several interviewees warn against generic contracts, advising states instead to write contracts that reflect their particular circumstances and expectations,” the study says. “In guidance prepared by CMS, the agency notes that managed care arrangements can promote the use of community-based services and provide data to measure quality, but also cautions that such accomplishments require that carefully constructed contract language and incentives are in place.”

The number of MLTSS beneficiaries covered by managed care was about 173,600 in 2008. Only 11 states operate capitated MLTSS programs.

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.