NCQA has published an expanded set of measures, guidelines, and technical specifications to assess standardized, equitable physician practice quality, using data collected from electronic medical records in addition to administrative claim data and paper medical records. These new data sets are available in HEDIS Technical Specifications for Physician Measurement, which contains more than 40 measures of clinical quality, sets standards for the measurement of the cost of care, and provides standardized methods of data collection at the physician office level.... A new strategy proposed by America's Health Insurance Plans would create an independent entity to compare the safety and efficacy of medical procedures and technologies, advocate steps to promote transparency of health care information, speed up the adoption of best practices, and create a new patient-centered dispute resolution mechanism. The strategy also calls for reforming the Food and Drug Administration to improve its ability to assess the long-term safety and effectiveness of newly approved drugs and devices.... Physicians do not routinely consider patients' out-of-pocket costs when recommending expensive medical care, according to researchers at the Center for Studying Health System Change. Although almost 80 percent of physicians consider patient costs when prescribing a generic over a brand-name medication, far fewer consider costs when deciding what diagnostic tests to recommend (40.2 percent) or deciding whether to hospitalize a patient when outpatient treatment is an option (51.2 percent).
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.
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?
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.
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.