Alice G. Gosfield
HEALTH PLAN 2009

Alice G. Gosfield

Alice G. Gosfield is a principal at Gosfield & Associates in Philadelphia. She's a nationally known health care lawyer and a former chairwoman of the National Committee for Quality Assurance.

As health care expenses go up, dissatisfaction with the style of care with controlled costs will lead to more stratification in the industry in the form of more boutique, concierge, and pay-as-you-go elements in a world in which consumers carry more of the cost of their health care.

More stratification

Those who can pay will buy more amenities. While physicians and hospitals will seek to provide more of these amenity- and convenience-based "luxury" services, there will also be more stratification in terms of payers differentiating more among providers, allowing higher quality providers to be paid differently.

History to date has led to care that is paid for at the lowest common denominator or, at best, the middle of the curve. New approaches will go beyond pay-for-performance add-ons, but will allow truly different mechanisms of payment to coexist side by side as payer management systems become more sophisticated.

Bargaining

This will include more case rates and lowered administrative burden from decreased medical management and control features coming from plans that will bargain more explicitly for the level of care for which they will pay. Stratification will be developed to carve out 80–20 type conditions for different approaches, meaning that more attention will be paid to the bigger ticket/higher volume conditions.

Quality matters

This does not necessarily mean a $20 fee where other providers get a $10 fee, but more payment that reflects evidence-based medicine and quality performance.

Nonphysician practitioners will have increased responsibilities and legally recognized authority and will be included in global/team practitioner payment models, where physicians are saved for their highest and best use, permitting nonphysicians to perform more services previously reserved to physicians alone.

Some of this will be reflected in liberalized state laws that give to nonphysicians prescribing and procedural authority and some will be found in contractual payment models that put physicians in more of a supervisory and collaborative role on these issues, permitting nonphysician clinicians to actually be hands-on for the service.

As access to providers becomes more problematic in the midst of the malpractice insurance crisis of the early part of this decade, there will be state-level alternative compensation systems for tort.

Performance info

Far more information will be available regarding performance of individual physicians, physician groups, hospitals, and their medical staffs.

HMOs that survive in the year 2009 will have differentiated themselves among those that merely pay claims as being far more involved in helping their providers deliver appropriate care as opposed to merely administratively managing to actuarial projections.

Plans and providers will be far more connected electronically and will have more consistent IT systems across their enterprises so they can interact more quickly.

Fraud-and-abuse enforcement will flourish and expand far more into nongovernmental programs. Compliance will become more integrated into the overall health care mission and will no longer be an option for provider, plans, suppliers, and physicians.

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.