Whatsoever the 109th Congress soweth, so shall the 110th Congress reap. Just before adjourning last month, the outgoing Congress passed legislation that would set up a pay-for-performance program in Medicare. The reviews, by critics who can wield votes as well as opinions, have been mixed, and there is already doubt about the law surviving in its present form.

Democratic Rep. Pete Stark, a name very much bound to health care debates during much of the Clinton administration, is rising from the ashes thanks to the Democratic takeover of the House in November. Stark is slated to become chairman of the House Ways and Means Subcommittee on Health.

"The entire concept of pay for performance is offensive," he tells the New York Times. Providing high quality care is the bare-bones job definition of a physician, he says. Doctors shouldn't be paid more for doing so.

The legislation freezes Medicare payments for 2007 at the current level, but also provides a 1.5 percent increase for physicians who agree to report data on how well they manage things like blood pressure for diabetics or medications for heart attack patients.

Catherine G. Cohen, vice president of the American Academy of Ophthalmology, says that the measure could "impose a significant new burden on doctors' offices."

Stakes are high. Health plans have long sought a system of standards to hold physicians to, something not lost on Republican Rep. Charlie Norwood, who tells the Times that neither insurers nor government should tell doctors how to practice.

Not lost on anybody is the likelihood that health plans will have an easier time installing pay-for-performance programs if they claim to be following the government's example.

Of course, most health plans already pay for performance. However, there has long been a call for a single program based on generally accepted national practice guidelines because of the wide variation in quality from region to region.

Who should measure physician performance and how it should be done is increasingly under fire, and P4P proponents are not going to give up without a battle.

"Medicare pays the same amount regardless of quality," Republican Sen. Charles E. Grassley tells the Times. He adds that Medicare "rewards poor quality" by paying doctors, according to the newspaper, to treat complications caused by their mistakes.

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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.