More on the pay-for-performance push. MedVantage, a consulting company, says that more such programs (42 percent) are now aimed at specialty care. But physicians are wary. "There are a lot of established markers for quality care in our specialty, but often even in those, there is disagreement," Ronald Vender, MD, a partner at the Gastroenterology Center of Connecticut, tells the Wall Street Journal.... The nation's HMOs operated on a slim profit margin in the first three months of 2004, according to Weiss Ratings. This, despite the fact that they reported $3 billion in profit, representing a $742 million increase over the $2.3 billion the companies earned for the same period in 2003. "Although the industry has enjoyed an increase in revenues by raising premiums, insurers have also had to deal with the rising cost of medical care as a result of more open networks, an aging population, expensive medical advances, and an inefficient health care system," says Melissa Gannon, Weiss's vice president.... Health coverage is not a factor in determining the level of care children ages four months to 35 months receive in the U.S., according to a study in December issue of Pediatrics. Neither is race, ethnicity, or income. Then why, according to the study, is one-third of that population not getting the preventive care it needs? "I think, frankly, [providers] are not doing the kind of job they should be doing," Barry Zuckerman, MD, chief of pediatrics at Boston Medical Center, tells the Boston Herald.... CMS has selected the 26 regions of the country where Medicare Advantage will offer PPOs. It also unveiled last month the 34 regions where private drug coverage will be offered to beneficiaries. The reaction of health plan officials, who wanted more regions, was mixed. Karen Ignagni, president and CEO of America's Health Insurance Plans, appreciated that CMS "really worked hard" to come up with the plan. Alissa Fox, policy director for Blue Cross and Blue Shield Association, said that "This makes it more difficult for the Blues plans."

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.