When Aetna U.S. Healthcare and Texas's attorney general settled a lawsuit over financial incentives last month, the AMA viewed it as an improvement in Aetna's physician relations. However, if the Texas deal ignites a trend away from the use of incentives to keep utilization down, then some capitated physicians worry it will put them in a tight spot.

"This is going to put a tremendous squeeze on primary care physicians," says Walter Lane, M.D., a Florida family practice doctor. "They're saying, 'We're not going to reward you if you manage well.' If you are unlucky, you're penalized."

Under the agreement, Aetna will stop paying incentives to physicians who limit services to keep the cost of care within a budget. Doctors who exceed budgets because of needed care cannot be penalized.

The agreement comes a year and a half after then-Attorney General Dan Morales sued six Texas HMOs, alleging fraud and deceptive trade practices. A number of managed care members complained that they were denied needed care without proper explanation or because of HMOs' financial inducements to physicians.

The settlement applies only to Aetna; Cornyn hopes the other five HMOs will agree to similar provisions. Under the deal, Aetna will:

  • End capitation for physicians and groups with fewer than 100 Aetna members;
  • Offer financial incentives to physicians for providing preventive care;
  • Define medical necessity so members understand the basis for coverage decisions;
  • Stop forcing physicians to accept all-or-nothing products clauses in contracts.

In exchange, the state will not pursue fines against Aetna. Originally, Texas had sought $10,000 per violation.

Lane is concerned that the agreement "emasculates" managed care and capitated physicians' ability to practice it.

"It's another tool out of the tool box," he says. "We are very close to the point where managed care is not managed care — it's just cost containment, not allocating services on a rational basis."

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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.

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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.