Medicare officials plan to launch a pay-for-performance demonstration project next year for solo and small physician practices. The initiative will be a pay-for-reporting program in its first year in order to provide baseline information on the approximately 800 participating practices in Arkansas, California, Massachusetts, and Utah, according to the Centers for Medicare & Medicaid Services. After that, practices will be able to earn yearly incentives of up to $50,000, with a $10,000 maximum per physician.... Meanwhile, Mark McClellan says that higher-income Medicare beneficiaries should pay higher premiums to ensure the program's financial viability. McClellan, former CMS administrator, notes that beginning next year, beneficiaries with annual incomes of $80,000 will be required to pay a surcharge for the first time. That will affect 4 percent of beneficiaries, or 1.8 million individuals, and McClellan thinks that is a good first step. Policymakers should increase the surcharges even more, he says.... This one sneaked up on everybody, apparently. A quarter of Fortune 1000 companies are expected to have on-site clinics by the end of 2007, says Watson Wyatt Worldwide. About 15 percent have them now. "The trend has caught on so quickly that there is little comparative data: Watson Wyatt didn't even ask the question until this year," reports the Washington Post. Those that have the clinics are raving. Employees are more likely to seek preventive care when the doctor is just down the hall. The clinics also cut down on work time lost when employees go to a doctor outside the building.... The world's largest retailer will put consumer-directed health care to the test in the big way come Jan. 1, 2007. Wal-Mart Stores is set to offer new employees high-deductible plans as a "massive test" that it hopes will result in lower costs by "making individuals responsible for spending decisions," reports the Wall Street Journal. New employees will be able to enroll in a health plan with an $11 monthly premium and a $1,000 deductible, or a plan with a $17 monthly premium and a $3,000 deductible. Wal-Mart expects to contribute as much as $2,400 to the HSAs annually, says the Journal.

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.