Everyone is afraid of being sued. Health plans don't want to be sued by their physicians. Neither plans nor doctors want to be sued by patients. And so America's zeal for litigation has emasculated one tool meant to provide accountability in health care: the hated National Practitioner Data Bank.

The Office of the Inspector General's revelation that 84 percent of HMOs did not once report evidence of an adverse event — malpractice settlement, licensure action, etc. — to the Data Bank during the '90s triggered a flood of excuses. HMO insiders told the New York Times that liability concerns lead some plans to strike quiet deals with physicians: Quit the provider panel in exchange for not being reported. Plans depend on hospitals to do the dirty work — though 60 percent of hospitals, also fearful of suits because it's hard to prove individual responsibility, made no reports.

In a USA Today essay, American Association of Health Plans President Karen Ignagni wrote that HMOs are doing what they think is the law — reporting physicians to state boards. The OIG said health plans' reliance on contracted physicians, instead of salaried doctors, may have contributed to the fact that they made only 715 reports during the '90s. Using the Institute of Medicine's 1999 report on safety as a gauge, at least 440,000 people died in hospitals over that period because of medical errors.

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.