For years, when there was talk about physician/insurer tension, the insurer was understood to be an HMO or some other sort of managed care entity. Now, nationwide, physicians are feeling abandoned by another sort of insurer — the companies that had covered them for malpractice.

Those premiums are going up so quickly that many physicians are feeling pressure to stop offering certain procedures, to move to states that are friendlier to medical practices, or even to retire early.

Exactly how this eventually affects HMOs and other managed care organizations is, at this point, anybody's guess.

Hospitals are very much under the gun. The stress that the current provider shortage places on them and on health plans has long been noted. Outlandish malpractice premium hikes exacerbate the situation — and, as USA Today reports, "outlandish" may well be the correct word.

Consider the case of Joe Prud'homme, MD, an orthopedic surgeon who used to work in Beckley, W.Va., until his annual malpractice insurance premium doubled to more than $80,000. Enough is enough, said Prud'homme, and moved 80 miles to the southeast to Blacksburg, Va., where he now pays $18,000.

HMOs making an effort to improve customer service — the customer in this case being members — may also run into some problems.

John Schmitt, MD, an Ob/Gyn in Raleigh, N.C., predicts that patients will wind up paying more and resenting it.

"It won't be immediately passed on to the patients, as we are locked into managed care contracts on a fixed payment schedule," Schmitt wrote to a state senator. "But we all will soon pay for these increases by way of higher premiums, out-of-pocket expenses and deductibles."

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.