Uncle Sam has decided to get behind the pay-for-performance effort in a big way, something some physician associations are less than thrilled about. About 140 standard measures of doctor performance in 34 clinical areas could be in place by the end of this year thanks to an agreement reached between the American Medical Association and Congress.

The hope is that the government will use the P4P program to measure payment to physicians who treat Medicare enrollees. The agreement says that "By the end of 2007, physician groups will have developed performance measures to cover a majority of Medicare spending for physician services."

As the New York Times reports, the implications are far-reaching. "The Medicare payment for each physician service was frozen this year. Under current law, doctors face cuts of more than 4.5 percent in each of the next eight years. Congress has often intervened to prevent or delay such cuts. It could easily stipulate that doctors must report measures of clinical performance as a condition of getting even a small increase in Medicare fees."

The government says that the standards would allow payment to be based in part on, for instance, how conscientious a doctor is in prescribing beta-blockers to recovering heart attack patients.

The AMA had warned that many specialty associations may find "it difficult if not impossible" to meet the deadlines of the agreement. Sure enough, no sooner had the agreement been announced last month than 10 physician associations representing specialists protested, saying that the AMA did not insist that adequate safeguards be put in place to ensure that doctors would be paid fairly for treating Medicare patients.

"We are dismayed that an agreement was reached on issues that are critical to the future of our specialties and our patients without our participation or knowledge," the physician specialty associations wrote to Congress. "The American Medical Association cannot be the sole representative for the groups who are paramount to the development and implementation of quality measures."

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.