Pay-for-performance (P4P) programs may be especially effective in improving quality for those physicians who currently don’t perform well, according to a study in the Journal for Healthcare Quality.

Judy Ying Chen, MD, lead author and director of clinical development at Health Benchmarks, a division of IMS Health, also says the positive benefit of the P4P program may not be realized until the third or fourth year of the program.

“Our findings reveal that a P4P program appears to be effective in aiding low-performing physicians to sustain improvement,” says Chen.

The researchers wanted to assess the effect of a P4P program (which paid an additional 1.5 to 7.5 percent of the physicians’ base professional fee) on quality scores for physicians who practiced in a preferred provider organization (PPO) setting over a four-year period, compared with a group of physicians practicing in a PPO setting without a P4P program. They reviewed administrative claims data from a commercial PPO health plan in Hawaii (the study group), which implemented a P4P program and a commercial PPO health plan in the South (the comparison group) without any performance incentive programs.

Results showed that a P4P program in a PPO setting can improve quality of care. This was especially true for selected quality measures, such as mammography, cervical cancer screening, and childhood immunization practices.

The low performing physicians using P4P improved significantly more than the comparison group (which did not implement a P4P program) for many measures. This was especially true in the first and second year of measurement. However, improvements for low performers in the non-P4P comparison group consistently decreased with time.

Quality scores of low-performing physicians

Overall, quality scores for both groups were good; physicians performed quality care for at least 70% of the eligible patients in all quality measures except colorectal cancer screening.

Source: Chen JY, Kang N, Juarez DT, et al. Impact of a pay-for-performance program on low-performing physicians. J for Healthcare Quality. 2010;32(1):13–22.

ACE inhibitor use

Mammography

Cervical cancer screening

Colorectal cancer screening

Hemoglobin A1c testing

Varicella vaccine

Mumps, measles, rubella vaccine

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.