Pay-for-performance programs are gaining in prevalence — nowhere more so than among HMOs. More than half of 252 HMOs surveyed said they implement P4P programs in contracts with physicians and hospitals. Of the 126 HMOs with P4P programs, nearly 90 percent had programs for physicians and 38 percent had programs for hospitals, according to the survey published in the New England Journal of Medicine.

These arrangements tend to be associated with HMOs that use primary care physicians as gatekeepers to specialty care, use capitation arrangements, or are themselves rewarded by performance-based incentives.

Researchers surveyed insurers that offered commercial HMOs in 41 U.S. cities. Of 113 HMOs that used P4P programs for physicians, 13 percent focused on the individual physician as the unit of payment. That is, doctors' performance was rated and rewarded based on their individual ratings rather than that of the medical group to which they belong. In one third of the programs, only the top-rated physicians or physician groups were rewarded. Nearly two thirds offered rewards for reaching a performance threshold. The bonus potential for physicians in these programs was generally equal to 5 percent of payments from the plan.

These findings have implications beyond the commercial HMO arena. If the Centers for Medicaid & Medicare Services incorporates P4P into Medicare Advantage plans, incentives may eventually flow downstream to providers.

Prevalence of P4P programs, according to HMO characteristics

Source: Rosenthal MB, et al. Pay for performance in commercial HMOs. N Engl J Med. 2006:355:1895–1902.

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.