Physicians providing care for Medicare fee-for-service beneficiaries will start to get bonuses or penalties depending on their performance as the Centers for Medicare & Medicaid Services phases in its “value based payment modifier” system between 2015 and 2017 ( An in-your-face reminder of that was delivered to 20,000 doctors in Kansas, Iowa, Missouri, and Nebraska. They were issued reports ( showing how much their patients cost the system on average, as well as the quality of care provided.

About those quality measures, there’s been much discussion. CMS admits that it is still trying to figure out exactly how to measure quality while taking into account the differences in health status of patients and how “to select physicians’ peer groups for comparison.” For its reports, CMS chose 28 measures, “most of which are HEDIS measures….”

Often, Medicare and commercial insurers borrow each other’s techniques, but what plans use now to measure physician cost-effectiveness was of little help with Medicare beneficiaries, according to a report by the General Accounting Office (

In addition, CMS found more in the way of quality measurement tools for primary care doctors than for specialists, saying in an August 2011 report that CMS prefers to use quality measures endorsed by the National Quality Forum, but adding that “many of the measures that specialty societies have created have not yet achieved NQF endorsement.”

In the CMS survey, Physician Quality Reporting System measures were used to give the doctors in the four states an idea of what physicians in their region spend for treating specific diseases and conditions — the cost of testing, admissions, procedures, and everything else, including the doctor’s compensation.

Case cost by physician and condition

Case cost by physician and condition

And here’s how the physicians fared in terms of quality — in this case, the percentage of patients who received the recommended service for a particular condition.

Quality of care not so great

Mean performance rate on measures in the critical category for physicians in Iowa, Kansas, Missouri, Nebraska

Mean performance rate on measures in the critical category for physicians in Iowa, Kansas, Missouri, Nebraska

Source: Centers for Medicare & Medicaid Services, “Physician Feedback Program: 2010 Individual Physician Quality and Resource Use Reports,” April 5, 2012.

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.