Physician practice managers are in a central position because they interact with health plans that determine quality targets and financial incentives, such as pay-for-performance programs, and with the physicians and other providers in their organizations.

A study published in Medical Care Research and Review bears this out. Researchers interviewed practice managers about how financial incentives are implemented in physician practices and the attitudes and perceptions they had toward P4P programs.

They interviewed 28 practice managers in 25 organizations in Massachusetts. The researchers made five key findings about managers' perspectives on P4P:

  • Quality incentives are better than utilization incentives,
  • Quality incentives are seen as bonus rewards,
  • Quality incentives are seen as agents for change,
  • Providers do not feel they have control over meeting quality goals, and
  • The ways in which quality is measured are problematic.

The general attitude of practice executives was that quality incentives are far more aligned with physicians' clinical goals and professional philosophy than are utilization incentives. The researchers found that many of the practice executives believed that physicians already strive to provide good quality of care regardless of financial incentives. How incentives are distributed (e.g., give to all providers, retain by the organization, or base on a payer's performance on quality targets) may have an effect on quality. Health plans take note: The authors suggest that performance monitoring and feedback may be enough to improve quality. So put away that carrot.

Distributing incentive dollars and impact on quality
Mechanism — and its potential mode of impact on quality
Equal distribution to all providers May enhance group work; may remove power of incentive from individual physicians.
Provider's performance judged by payer's quality targets Is the most powerful incentive to affect provider behavior directly.
Provider's performance judged by practice-based incentive schemes Decreases power of the incentive direct from payer. May affect performance in other ways.
Money retained wholly by organization Least powerful incentives to physicians. May produce change in quality of care by implementing systems-level changes.
Hybrid approach May produce change at provider level and at systems level to improve quality of care.

Source: Incentive implementation in physician practices: A qualitative study of practice executive perspectives on pay for performance. Medical Care Research and Review. 2006 63:73S–95S.

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.