Joseph Burns
Contributing Editor

The problem with managed care is insurance, says Georganne Chapin, president and CEO of Hudson Health Plan in Tarrytown, N.Y. Her solution to one of the most difficult problems health insurers face involves removing the risk-financing mechanism. Adopting a single-payer health care system would allow plans to do what they do best: deliver patient care, she says.

“I believe in managed care. I just don’t believe in insurance,” she says. “Managed care is the only way to take care of people because it’s designed to give people the right care at the right level and to get waste out of the system.

“Health plans do so many things well and those things are more important than taking risk with money. We do care management, network building, and patient identification. We understand how to work with providers and how to build care teams, and we’ve developed successful ways to provide incentives.

“Eliminating the financial risk-taking of health insurance would be a good thing,” Chapin explains. “If we somehow cut out the current financial mechanism, we would have one big risk pool, meaning a single-payer system. Then health plans could solve our health care problems.

“What we’re doing now is crazy and everyone knows it’s unsustainable,” she adds. “That’s before we implement all aspects of the Affordable Care Act (ACA). And the affordable part of the ACA is perhaps the biggest problem. The law will not make health care affordable because it’s the result of compromises made to get it passed.”

She concedes, however, that the law is significant legislation that begins to address some of the problems that have long plagued insurers, providers, and patients. “It’s great that some people who had no way to get coverage previously, such as children up to age 26, now have health insurance under the law,” she says. “It’s problematic, however, because those children have to live at home or at least in the same area as their parents. But at least it works for some.”

Chapin worries that, when hospitals and physicians form accountable care organizations, many will fail to manage both patient care and the financial risk of delivering care. “We see how hospitals and physicians want to become managed care companies,” she says. “But I’m not sure they’re equipped to handle the risk and I’m not sure that the expectations we have for these organizations are realistic.

“This new system we’re building will still be fragmented,” she comments. “It will still be plagued by temporary eligibility. Those who will be newly insured will be eligible, but only for a short time because many will be unable to afford coverage. That makes all the predictions about how many new people will be covered extremely optimistic. People won’t be able to make their payments because premiums will keep going up. At the same time, fewer employers are offering coverage because they can’t afford it, either.

“It’s easy to be a nihilist, but, in truth, we have to keep doing what we do well and that’s care coordination,” Chapin adds. “Our health plan had a chronic illness demonstration project and our intention was to be the forerunner of the patient-centered health home.”

A social component of care

“We had very sick Medicaid patients in a fee-for-service system and we were paid to do care coordination the way it should be done. We found that, in this population, people’s medical problems have a social component. Medicaid allows us to address those problems and our regular health insurance system does not. So, in truth, we should be fixing both our medical system and our social welfare system together. That’s what we did and it worked.”-

Georganne Chapin [r] with Margaret Leonard, RN

Health Plan 2020


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.