New York state would seek a waiver from the Centers for Medicaid & Medicare Services to contract with health plans to cover people who are eligible for both Medicaid and Medicare, under a new proposal. The state’s 700,000 dual-eligibles consume about 45 percent of Medicaid and 41 percent of Medicare spending. A proposal by the state’s Department of Health would allow the state to deal with plans and accountable care organizations under subcapitation arrangements (http://bit.ly/sAQgEG).

The report outlining the recommendations points out that New York’s PACE (Programs of All-Inclusive Care for the Elderly) enrollment is the highest in the country and that the state’s Medicare Advantage Plus program was one of the first to contract with a health insurer that covers both Medicaid and Medicare beneficiaries.

Now, however, state officials say that growing enrollment has made the programs less functional.

Under the proposal, “New York would partner through ‘sub-capitation arrangements’ with health plans and/or integrated provider groups that have sufficient network capacity and are capable of delivering care and assuming risk for the full spectrum of Medicare and Medicaid covered services.”

State officials claim that everybody wins: Members will have access to better care, the federal government will spend less, and state providers and health plans will be able to “share in savings that result from care integration.”

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.