Back in 2006 with the passage of the Tax Relief and Health Care Act, Centers for Medicare & Medicaid Services (CMS) was charged with establishing a physician quality reporting system that would include incentive payments to eligible providers. This Physician Quality Reporting Initiative (PQRI) initially targeted individual providers, but in 2010, group practices may also qualify to earn PQRI incentives equal to 2 percent of their total estimated payments under the Medicare Part B physician fee schedule.

The bonus is relatively small, says Mark L. Metersky, MD, professor of medicine in the division of pulmonary and critical care medicine at the University of Connecticut School of Medicine and author of the paper titled “The Medicare Physician Quality Reporting Initiative: What Do Chest Physicians Need to Know?” The small size may deter some physicians, but Metersky advises otherwise.

“The big reason that many physicians should consider this is that it will prepare them for the future. We’re likely to see more and more programs where this type of reporting will be linked to payment in some way or another,” says Metersky.

Commercial insurers often follow CMS’s lead in terms of payment. “All you have to do is look at the decision by CMS not to pay for consults; many payers have jumped on that bandwagon.”

There’s also no double-dipping allowed — individual providers who are members of a group practice selected to participate in the group practice reporting option (GPRO) are not eligible to separately earn a PQRI incentive payment as an individual provider.

Each group practice will be required to report 26 quality measures. A list of the measures for 2010 can be found in the “2010 PQRI GPRO Disease Modules and Preventive Care Measures.”

A description of each of the 26 measures can be found in the “2010 PQRI GPRO Narrative Measure Specifications.” Both documents are on CMS’s Web site: www.cms.gov.

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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.