The Affordable Care Act’s offer to the states to make poor, childless adults who are not disabled eligible for Medicaid, although accompanied by a substantial subsidy, isn’t playing well in some states. But there is one state where similar provisions have been in effect since 2001: Arizona.

“Overall, the findings from Arizona suggest that as states expand coverage to adults under reform, meeting their health care needs will likely require a broad package of benefits, specialized treatment services, and care and disease management programs for those with significant and complex mental and physical health conditions …” says a white paper by the Kaiser Family Foundation. States will also need to come up with strategies to connect these new beneficiaries with a medical home or other primary care provider so that they get the preventive care they need.

The paper, “Health Care Use and Chronic Conditions Among Childless Adult Medicaid Enrollees in Arizona (http://kff.org/medicaid/upload/8310.pdf),” states that there were about 17 million nonelderly uninsured adults who had income at or below 133 percent of the federal poverty level in 2010 — the new cutoff for Medicaid. “These uninsured adults account for 37 percent of all the uninsured in the United States, and nearly seven in ten of them are adults without dependent children.”

The study looks at utilization patterns of 48,857 childless adults, 92,118 parents, and 31,340 disabled adults, and includes an analysis of adults who were high users of health care services in Arizona in 2007.

It finds that mental illness is the most prevalent condition in this cohort, affecting 70 percent of high users of inpatient hospital care, 64 percent of high users of emergency room care, and 60 percent of high users of physician visits. “These findings suggest that care management strategies such as medical homes, chronic disease management programs, and targeted health outcomes may all be important for providing care to childless adults covered by the expansion.”

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.