Approximately 25 percent of physician organizations pay their doctors on a purely fee-for-service basis, 25 percent pay them on a purely prospective (capitation or some method completely unrelated to productivity) basis, and 50 percent pay the physicians by using blends of retrospective and prospective payment methods, according to a study by researchers in the School of Public Health at the University of California– Berkeley. Medical groups and IPAs in strong managed care markets are significantly less likely to use fee-for-service methods to pay their physician members than are organizations in markets with less managed care presence.

Medical groups and IPAs tend to blend elements of fee-for-service, salary, and subcapitation for their physician members, as each payment method offers advantages in terms of motivating productivity, cooperation, and practice efficiency.

"Physician organizations in markets with extensive HMO penetration have been most willing to shift away from fee-for-service and towards individual physician payment methods that reward efficiency rather than productivity," says the lead investigator, James C. Robinson, PhD. "By implication, the contemporary shift among insurers away from capitation for physician organizations will encourage these organizations to shift their individual physicians back to fee-for-service, thereby stimulating more billable claims, more revenues for the physician organizations, and higher expenses for the insurers."

SOURCE: THE ALIGNMENT AND BLENDING OF PAYMENT INCENTIVES WITHIN PHYSICIAN ORGANIZATIONS. HEALTH SERVICES RESEARCH: OCTOBER 2004

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.