John Marcille

We die from the moment of birth, and even the ground we walk upon has a beginning and — the physicists (or is it cosmologists?) tell us — an end that we won’t witness. The fee-for-service (FFS) payment system spins on the circle of life, as well.

It has been dying for an awfully long time, as our cover story on page 21 notes. Will we ever see the end of FFS? It won’t happen this year, or maybe even this decade, but little engines of change rev throughout the health care system.

The accountable care organizations and patient-centered medical homes that the Affordable Care Act promotes try to push FFS to the side. Can they? Contributing Editor Joseph Burns notes FFS’s stubborn refusal to go. It is entangled with the Current Procedural Terminology system, for one thing. And most health plans lack the information systems needed to sustain whatever might replace FFS. Contracts with thousands of provider groups would need to be rewritten.

The Catalyst for Payment Reform, an organization headed by Suzanne F. Delbanco, PhD, says that only 11% of payment to providers is not FFS. It “might be at 13% in the next year or two,” says Jim Evans, a McKesson consultant.

Still, are there not some health care operations where FFS makes sense?

What if an asteroid hadn’t ended the age of dinosaurs? What if they just decided to not show up for work one day? The Centers for Medicare & Medicaid Services reports that nearly 10,000 physicians opted out of Medicare, which is mostly FFS, in 2012, more than twice the number of doctors who had made that same decision in 2009.

Physicians have long bristled at CMS’s now-you-don’t-see-it, now-you-do pay raises. This time looms the threat that Medicare payments might be slashed by about 25% next year. Congress might step in again, but doctors tire of the game.

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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.