Don’t look now payers, but expect to be double-teamed by hospitals and physicians. With Medicare payments and the Prospective Payment System getting squeezed, the biggest revenue stream for both hospitals and physicians is — wait for it — you. And the need for hospitals and physicians to collaborate on care management to reduce costs is coming from the top down in the case of hospitals.

A PricewaterhouseCoopers Health Research Institute report, From Courtship to Marriage: A Two Part Series on Physician-Hospital Alignment, says that hospital CEOs surveyed “were bullish on the need to partner with physicians as a means of participating in accountable care organizations (ACOs) and other new payment arrangements.”

Physicians are also amenable to this arrangement — the report says 56 percent of doctors want to more closely align with a hospital to increase their income. Another 40 percent want to align to ensure a more consistent income stream. And perhaps the biggest reason for alignment is greater negotiating and market power, according to 68 percent of physicians.

When physicians join the hospital payroll they will be expecting an increase in income across specialties, according to the report. Interestingly, once employed by hospitals, physicians expect that half their compensation should be fixed salary, with the remainder related to incentives. The report says, “Physicians realize [that] the health system is changing to track and reward performance and that they can influence the quality and cost of care delivery at the institutional level.”

The report says that more than 80 percent of physicians expect to be paid the same or more than they are now. The average expectation was a 2.4 percent increase, ranging from 1 percent to 4.7 percent. Fewer than one in five physicians said they would accept a pay cut to work for a hospital.

How much of an increase in salary do you expect by working for a hospital?

Source: PricewaterhouseCoopers Health Research Institute. From courtship to marriage: A two-part series on physician-hospital alignment. April 2011

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.