MANAGED CARE March 2000. ©2000 MediMedia USA

Collecting information is one thing; interpreting it is another. National Health Information polled 466 provider groups; among the questions was, "If you have renegotiated a contract in the last 12 months, has the capitation rate increased, decreased, or stayed the same?" Answers given by providers contracting with HMOs seem to indicate that those physicians are seeing better days, but you shouldn't jump to conclusions.

"If a provider group rode the arbitrage to wild success one year and had massive profits, then its rate is going to go down the following year," says NHI President David Schwartz. "Something's going to change in that contract so that the HMO is not allowing the provider to win as big.

"On the other hand, if the provider group fails and loses money during the contract year, it's going to come back and say 'Look, if you want us to continue as an entity serving your members, we're going to absolutely need this much money to make it work,'" he continues. "So, I think a lot of the increases reported in the 1999 survey are reactions to poor performance among provider groups."

The only provider category that saw an overall decrease in its average capitation rate was hospitals — perhaps reflecting a growing perception among both providers and payers that hospital capitation may not be workable over the long run.

Capitation snapshot



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.