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Perspectives on Managed Care Trends

Posted by Matt Breese on Feb 21, 2017

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Managed care health insurance plans are intended to reduce consumer costs and improve the quality of patient care. In managed care plans, states and employers develop contracts with payers and managed care organizations (MCOs) to offer healthcare benefits and long-term care to members at a lower cost. The healthcare industry is seeing an increasing adoption of managed care models. According to a 2016 Kaiser Family Foundation Report, “As of July 2016, 39 states contracted with risk-based managed care organizations to serve their Medicaid enrollees.”

It is important for health organizations to monitor shifts in managed care because these often indicate changes about to occur in the entire healthcare system. For example, policy changes, such as a modification on the Affordable Care Act (ACA), will impact payer/PBM coverage as a result. 

Causes of the Managed Care Shift

The healthcare market is experiencing an increasingly level of sophistication and a greater amount of highly managed specialty drugs. A Medicaid Budget Survey conducted by The Kaiser Family Foundation revealed, “The vast majority of states identified high cost and specialty drugs as a significant cost driver for state Medicaid programs, most pointing specifically to hepatitis C antivirals.”

As a result, payers must control the massive costs associated with specialty drugs. In addition, providers must have access to the latest policy and pricing information.

Managed Care Trends in 2017

For payers and providers, staying up-to-date on managed care trends is essential. Modern Medicine Network predicts the following managed care trends will occur in 2017:

  • Increasing healthcare policy changes
  • Expanding options for consumer-directed healthcare
  • Merger activity among smaller insurers
  • Continuing pressure to reduce premiums
  • Growing popularity of high-deductible health plans (HDHPs)
  • Increasing focus on Medicare funding
  • Stronger collaborations between payers and providers
  • Expanding access to big data

In addition, the industry will see an increased focus on caring for chronic conditions. According to Medicare.gov:

“Some states are implementing a range of initiatives to coordinate and integrate care beyond traditional managed care. These initiatives are focused on improving care for populations with chronic and complex conditions, aligning payment incentives with performance goals, and building in accountability for high quality care.”

Clarifying Managed Care

Third party sources can help pharma companies better understand the complex managed market shifts. MMIT helps payers and pharma understand managed care through comprehensive formulary and policy information. These tools provide current data on coverage and restrictions across thousands of health plans.


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Topics: Industry Trends, Payer