The American Medical Association's January attack on so-called physician "gag rules" has been embraced by a number of HMOs since U.S. Healthcare came out in favor of minimal restrictions. Most recently,32 California HMOs have advocated open and unrestricted communication between physicians and patients about medical conditions and insurance issues such as reimbursement.

"Doctors have the obligation to communicate clearly and openly with their patients," says Arthur Southam, M.D., president and chief executive officer of CareAmerica, which has about 230,000 members.

The California Association of HMOs (CAHMO) has developed guidelines for patient-physician communication that members such as Aetna, PacifiCare, Cigna and Health Net say they will follow. AMA lawyers claimed that Aetna and Cigna contracts contain gag rules; both companies deny it.

Clauses that impede physician-patient communication won't be deleted from contracts immediately. CAHMO members have hundreds of agreements with physicians in California.

As these contracts come up for renewal, the HMOs will inspect them to determine whether they violate the announced guidelines, says Alan Tomiyama, spokesman for CAHMO.

During the past three years, pharmaceutical companies laid off thousands of detailers to reduce costs and shifted attention to decision makers who control drug formularies at managed care organizations.

That strategy is slowly changing. Some manufacturers are increasing their sales forces to target the increasing number of physicians who contract with managed care organizations, says a study by the consulting company Scott-Levin Associates of Newtown, Pa.

Product promotion to physicians working with managed care organizations has jumped 40 percent in three years, while detailing to physicians without managed care ties has dropped nearly 50 percent.

Drug manufacturers continue to detail pharmacy decision makers at managed care organizations, but are realizing that physicians still exercise choice among competing products on a drug formulary.

Not too long ago, drug company executives thought they could reach managed care by marketing to a relatively small number of influential pharmacy executives, says Joy Scott, CEO of Scott-Levin. "Companies are learning, though, that physicians are quite independent in their prescribing habits."

Not so well known as the NCQA, the Medical Quality Commission is also an accrediting body, but unlike the National Committee for Quality Assurance, which accredits health plans, the commission accredits medical groups.

An independent panel of health care professionals spends about two days visiting physicians' offices and surveys them in 14 areas that include 152 standards.

The nonprofit organization, established in 1991, has accredited 26 medical groups, predominantly on the West Coast. Recently, the commission decided to begin accrediting independent practice associations that provide some form of capitated care.

Officials hope to move beyond their California base and become recognized as a national accrediting body.

— Paul Wynn

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.