In a effort that will be watched by health plans and physician associations nationwide, Premera Blue Cross of Washington puts doctors into tiers according to how well they help control costs. Physicians considered most efficient are placed in the

lower-cost tier. The Washington State Medical Association's reaction is that tiering doesn't make sense without outcomes measurement. Jeffrey Collins, MD, the president-elect of the physician organization, says that using cost data alone could be hazardous.

"I know the health plan thinks it can figure it out with a data system," Collins tells AMNews. "But if you have someone who is really ill, there may be no relationship between the cost of care and the quality of care."

This unease exists despite Premera's promise to adjust the measurements for case mix and severity in a way that should prevent physician groups with many patients that have more costly problems from being penalized.

The system, called Dimensions, tracks costs at large clinics, representing about 15 percent of doctors in the Premera system.

Paul Ginsburg, director of the Center for Studying Health System Change, tells AMNews that he sees "only positives" coming out of such a move — such as lower premium costs for patients who can't currently buy insurance.

"If the groups that did poorly [in the profiling] look at why and try to change it, that would have a much greater impact on costs," he says.

Last year, Premera discussed preliminary cost analyses with medical group executives, giving them a chance to object to tier assignments. Dimensions was begun as a pilot last June, and Premera hopes to eventually roll it out to all of its customers.

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.