Whether you define managed care as a treatment philosophy or a payment mechanism, it's here to stay. Regardless of the mutations managed care has undergone in the last decade-plus, it is an entrenched part of the health care system — as confirmed by a recent study of physician practice revenue by the Center for Studying Health System Change. The survey indicates nothing to suggest that managed care is off to the dustbin — rather, that it is a continually evolving entity.

Managed care sources account for greater share of practice revenue

Nearly 91 percent of physicians contracted with MCOs in 2001. For those who do, almost 46 percent of practice revenue is derived from managed care sources, up 3 percentage points from 1997. In addition, the average number of managed care contacts per physician rose during this period — from 12.4 to 13.1 — despite consolidation in the managed care industry.

Capitation declines

No surprise here: The HSC surveyors found what others have indicated for at least two years — that capitation's heyday seems to be a memory of the '90s. For physicians with at least one managed care contract, the percentage of practice revenue derived from capitation had peaked by the turn of the century.

Financial incentives less often tied to paymentManaged care organizations have a history of trying to influence physician behavior by presenting physicians with incentive-laden contracts. The most common financial incentives — profiling, patient-satisfaction surveys, and quality-of-care metrics — however, seem to be waning. (By anecdote, however, it should be noted that during 2002, after the survey's end, many large MCOs began to endorse quality-of-care bonuses in physician contracts. See our cover story for more information.)

SOURCES: STRUNK BC, RESCHOVSKY JD. KINDER AND GENTLER: PHYSICIANS AND MANAGED CARE, 1997–2001; CENTER FOR STUDYING HEALTH SYSTEM CHANGE, WASHINGTON, 2002

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.