Physicians who have grown fed up with managed care to the point where they've set up "boutique" practices have gotten a lot of publicity in recent years — but not much guidance. Until now.

The American Medical Association for the first time established new ethical guidelines for doctors who opt to engage in boutique, or concierge, care.

"Retainer practices provide an opportunity for patients to develop a more personalized relationship with their physician," says Leonard Morse, MD, the chairman of the AMA's council on ethical and judicial affairs. "But physicians should also make sure that all patients, including those who do not pay retainer fees, continue to receive the same quality of care."

Setting up a boutique practice doesn't let physicians off the hook for providing urgent care, if it is needed. In addition, physicians are obligated to continue caring for HMO patients if those patients are unable to find other network doctors in the area. There should be no fee for transferring the medical records of patients who do find other doctors, the AMA says.

Here are some of the other AMA guidelines, which the organization adopted in June:

  • Patients have the freedom to select and supplement insurance for their health care on the basis of what appears to them to be an acceptable tradeoff between quality and cost.
  • When entering into a retainer contract, both parties must be clear about the terms of the relationship and must agree to them. Patients must be able to cancel a retainer contract without undue inconveniences or financial penalties.
  • Physicians must always ensure that medical care is provided only on the basis of scientific evidence, sound medical judgment, relevant professional guidelines, and concern for economic prudence. A retainer contract is not to be promoted as a promise of more or better diagnostic and therapeutic services.

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.