A majority of patients in consumer-directed health plans do not understand their coverage options and about 20 percent will skip preventive care because of cost, even though the services are free or very inexpensive.

Those are some of the findings in a study by Kaiser Permanente Northern California, which found that “consumers rarely understood that they did not have to pay the full price for preventive office visits and preventive tests. Those who mistakenly thought that their deductible applied to preventive care were significantly more likely than others to report avoiding preventive visits.”

The study — “In Consumer-Directed Health Plans, a Majority of Patients Were Unaware of Free or Low-Cost Preventive Care,” published in the Dec. 4, 2012 issue of Health Affairs — finds that 23.8 percent of respondents who thought that they had to pay for preventive services delayed or avoided care; only 7.8 percent of those who understood their coverage delayed or avoided care.

The services included an annual physical, cholesterol tests, diabetes screenings, mammograms, and colon cancer screenings. Not all of these were free, but the most costly was just $10.

The survey involved 456 Kaiser members younger than 65 who received their benefits through an employer with fewer than 50 workers in 2007. The deductibles were between $1,500 and $2,700 for individuals and $3,000 and $5,450 for families.

“Specifically, we asked participants to report whether the following types of services applied toward their health plan’s deductible: preventive office visits (for example, annual routine physicals), nonpreventive doctor’s office visits, preventive medical tests and screenings, and nonpreventive medical tests.”

The authors state that a major limitation of the study was its reliance on patient self-reporting rather than on utilization data collected in other ways. “However, it is important to note that knowledge of plan details is best assessed through patient self-reporting and that patient-initiated behavior, such as delays in care seeking, is challenging to identify directly in utilization data.”

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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.