Harris Methodist Health Plan will pay back $3.4 million to physicians who were penalized or who lost bonuses under the North Texas HMO's now-defunct pharmacy reimbursement policy. The plan, which has 325,000 members, also will pay a $100,000 fine to the state and pay up to $50,000 to the Texas Insurance Department for consulting help in rewriting its contracts with physicians.

The payments are part of a consent agreement that will settle a lawsuit filed against Harris in April. Of the $3.4 million, $2.6 million will go to physicians who exceeded their prescription drug budgets and $725,000 will go to physicians who lost bonuses when they failed to meet plan targets for spending on prescriptions, specialists and hospital care.

The settlement is the first penalty imposed under a state law that prohibits HMOs from using financial incentives that reward physicians for limiting medically necessary care.

The 6,000 physicians who work with Harris will receive new contracts starting this month. The plan expects it to take two to three months to distribute all of the new contracts. Physicians will then have 60 days to sign if they wish to continue in the Harris network. The newly offered deal limits bonuses tied to financial performance to 10 percent of a physician's base salary, and does not impose penalties for missing budget targets.

The Texas Department of Insurance is investigating other health plans, which it declined to identify, to see if they are improperly using financial incentives to limit medically needed care.

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.