Nearly 52 percent of doctors are familiar with the term “accountable care organization” and half of those say that their practice is already participating in one or expects to, says a working paper by UnitedHealth Group. “[I]nterest in participating was notably higher among PCPs — 55 percent of PCPs familiar with the term were pursuing or planned to pursue the option, compared to 38 percent of specialists,” says the working paper “Farewell to Fee-for-Service? A ‘Real-World’ Strategy for Health Care Payment Reform.”

Shared-savings and shared-risk arrangements that would have to be implemented to make ACOs viable appeal to some policy makers because they break with what they consider to be the perverse incentives of the fee-for-service system. “While most P4P programs offer relatively modest bonuses to individual providers that are based on a defined set of indicators within their scope of control — such as hospitals’ rates of infections or primary care physicians’ appropriate use of screening tests — shared-savings and shared risk programs typically offer incentives to a group of providers that reflect total population quality and costs,” says the paper.

As we’ve reported, many experts are less than convinced of ACOs’ potential (/archives/2012/4/herzlinger-predicts-acos-pcmhs-will-fail). The UnitedHealth Group report says key issues need to be addressed, including how patients are assigned to ACOs, who comes up with the expenditure targets, how might they be achieved, how quality will be measured, and how savings will be distributed. “Deeper issues include how providers are going to reorganize their practices to improve care delivery and control spending, and how to limit the risk of cost increases stemming from an increase in the market power of providers.”

Physicians’ familiarity with and interest in forming or joining an ACO

Are you familiar with the term accountable care organization? If so, is your practice considering joining or forming an accountable care organization?

Source: “Farewell to Fee-for-Service? A ‘Real-World’ Strategy for Health Care Payment Reform,” UnitedHealth Center for Health Reform & Modernization, December 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.