Compensation increased at a comparatively small rate from 2000 to 2001 for both primary care physicians and specialists, according to the Medical Group Management Association. The rate of increase for all primary care was only 1.2 percent — about half the previous year's change, and one third of the 3.4 percent increase in 1998–99. The main culprit is falling reimbursement rates for Medicare, according to William Jessee, MD, the MGMA's chief executive officer, who warns that compensation gains may disappear altogether this year due to a 5.4 percent Medicare reimbursement cut. He notes that while the Centers for Medicare and Medicaid Services plans to implement "MGMA-supported administrative adjustments" in 2003 to improve the measurement of physician productivity under Medicare, the agency needs to take additional administrative steps to address the additional 4.4 percent Medicare fee reduction projected next year.

"Physician group practices continue to serve a growing population of older Americans, despite the fact that annual Medicare reimbursement increases have lagged behind actual practice costs by an average of 2.7 percent each year for the last decade," Jessee says. "In the long run, this situation is financially unsustainable." MGMA proposals include the removal of Medicare-covered drugs from the definition of "physician services" and having CMS correct Medicare enrollment projection errors that have compounded the current payment shortfall.


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.