Most references to the elephant in the room usually say that no one is talking about it. That’s not the case with how the roles of primary care physicians and specialists will change in an industry that, thanks to health reform, might be dominated by accountable care organizations. Of course, not everyone agrees that ACOs will be the primary organizations — some say ACOs can’t work (http://bit.ly/JreCMX).

“It is too early to tell what effect ACOs will have on physicians’ income,” says Glen Stream, MD, president of the American Academy of Family Physicians. “That will likely vary among specialties. ACOs will need a solid foundation of primary care to be successful, but it is not clear that ACOs will include compensation formulas that reward the work of primary care physicians that makes them successful.”

On the other side, Tom Flannery, PhD, a partner in Mercer’s “human capital” business and a senior compensation consultant, thinks that ACOs will be a bulwark of health care no matter what the fate of the Affordable Care Act.

“Employers and employees are really tired of the cost of health care,” says Flannery. “If Washington doesn’t do something, then the industry is going to have to do something, or the employers are going to have to do something.”

Doctors surveyed in Medscape’s “Physician Compensation Report 2012” for the most part don’t know how ACOs might affect their income, and those who have an opinion are about evenly split as to whether their pay will rise or fall.

ACOs are expected to shift more power to primary care doctors, and it seems to be happening right now. “Pediatrics has historically been a low-paid specialty,” says Flannery, “but we’re beginning to see a shift in pediatrics, family medicine, internal medicine. It’s a recognition that the income levels need to go up to attract more people into primary care.”

Stream is cautious about drawing conclusions from the Medscape data. “Physician payment is complex and includes multiple variables that make it difficult to assign specific causal factors in these income changes,” he says.

Who’s up, who’s down since 2010

Source: Medscape Physician Compensation Report: 2012 Results

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.