Despite anecdotal reports to the contrary, the great majority — 87.6 percent — of physicians have contracts with managed care organizations. A new report from the Center for Studying Health Systems Change says that in fact, 70 percent of physicians had contracts with five or more managed care plans.

How does this affect a physician’s income? Compared with high-income physicians, a larger proportion of low-income physicians have no contracts.

Physicians without managed care contracts were more likely to have been in practice for more than 20 years, to work fewer than 40 hours per week, and to work in solo or duo practices. They were also more likely to practice in the West.

Physicians who are not board-certified are much more likely not to have managed care contracts, and “while the discussion is often about doctors not willing to contract with managed care plans, there are managed care plans that don’t want to contract with certain physicians because they lack board certification, which is a fairly common credentialing threshold for managed care plans,” says Alwyn Cassil, a spokeswoman for CSHSC and one of the study’s authors.

Options for physicians without managed care contracts range from seeing only patients covered by insurance products that do not include provider networks (such as fee-for-service Medicare) and accepting only cash for services and serving managed care patients as an out-of-network provider who can bill patients for charges beyond insurer allowances for out-of-network care.

Psychiatrists are the least likely specialists to have contracts with managed care — about 1 in 3 did not. The report suggests that this might have to do with low payment rates and a high degree of utilization management by health plans and managed behavioral health companies.

In contrast, pediatricians are very likely to have contracts with managed care — only 4.8 percent do not — in part because Medicaid managed care plans are a significant source of coverage for children.

Physicians with no managed care contracts

Source: Center for Studying Health System Change. Data Bulletin: A Snapshot of U.S. Physicians. September 2009.

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.