Expansion of Medicaid remains a huge part of health care ­reform. There has been a surge in Medicaid rolls, with about 6.3 million more people deemed eligible as of mid-January. Adults at or below 138% of the federal poverty level (FPL) can now sign up; before the ACA’s passage it was 106%.

Covering this population presents unique challenges, according to a survey by the Kaiser Family Foundation (https://kaiserfamilyfoundation.files.wordpress.com/2014/02/8552-the-uninsured-at-the-starting-line5.pdf) that “shows that almost half (47%) of uninsured ­report being uninsured for five years or more, and 18% report that they have never had coverage in their lifetime.”

There are gaps in coverage, even for insured adults, says the study. That’s even more pronounced for Medicaid recipients or those in nongroup coverage. “The most frequently reported services people say they need but lack coverage for are ancillary services such as dental, vision care, and chiropractic services,” says the study. “Lack of coverage for adult dental services in Medicaid — the most frequently reported service needed but excluded from coverage — had been a longstanding issue facing beneficiaries and providers, despite a particularly high need among the low-income population.”

Insured adults are much more likely to get care at doc offices than either the uninsured or Medicare beneficiaries. “Notably, 20% of uninsured adults report the emergency room as their usual source of care — almost double the share of adults with Medicaid and 10 times higher than adults with employer coverage.”

Length of time without coverage — currently uninsured adults

Note: Adults are ages 19–64

Problems with coverage — insured adults

Type of place used for usual source of care

Source: “The Uninsured at the Starting Line: Findings From the 2013 Kaiser Survey of Low-Income Americans and the ACA,” February 2014

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.