The age of health reform places increased emphasis on pro­viders, and it might behoove insurers to find the informal ways that some physicians are connected. Often doctors have “a history of working with each other, and likely have evolved natural communication channels,” says “Variation in Patient-Sharing Networks of Physicians Across the United States,” which was published in the July 18 edition of the Journal of the American Medical Association.

One of the things the study looks at is how best to form accountable care organizations (ACOs), a bulwark of health reform. “Insurers and policymakers who want to influence physician behavior might find it more efficient to identify candidate accountable care organizations in this fashion.”

The study adds, “These informal information-sharing networks of physicians differ from formal organizational structures (such as a physician group associated with a health plan, hospital, or independent practice association) in that they do not necessarily conform to the boundaries established by formal structures. Informal information-sharing networks among physicians may be seen as organic or natural rather than as artificial or deliberate.”

That’s not to say that formal organizations do not influence relationships among physicians. They clearly do. “Formal networks are important, as evidenced by the unsurprising finding that physicians associated with the same hospital are far more likely than other physicians to be connected. Yet this is not always the case.”

For instance, although hospital affiliation appears to be the reason physicians connect in Albuquerque, that’s not the case in Minneapolis/St. Paul.

The study looks at administrative data for nearly 4.6 million Medicare beneficiaries in 2006. The patients were seen by about 68,000 doctors in 51 urban and rural hospital referral regions (HRRs). The number of physicians per HRR ranged from 135 in Minot, N.D., to 8,197 in Boston. “There was substantial variation in network characteristics across HRRs,” the study notes, adding that connected physicians had “more similar patient panels in terms of the race or illness burden than unconnected physicians.”

The study adds that “physicians tend to share patients with colleagues who have similar personal traits, practice styles, and patient panels, although the influence of some of these traits is small in magnitude.”

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.