When financial incentives were withheld from 35 outpatient facilities owned and operated by Kaiser Permanente, physicians were less likely to screen for four quality indicators. In particular, the screening rate for cervical cancer dropped even lower than before the incentives were instituted, according to a study in the British Medical Journal.

The indicators were screenings for diabetes retinopathy and for cervical cancer; glycemic control in diabetes; and control of hypertension. Initially, incentives to screen for diabetic retinopathy and cervical cancer were removed. Payments were then reinstated for five years. During that period, screening for diabetic retinopathy rose from 84.9 percent to 88.1 percent. After those five years, the incentives were removed again, this time for four years, and resulted in a rate of 80.5 percent — lower than before the incentives were reintroduced.

Helen Lester, a professor of primary care at the University of Manchester in the United Kingdom and lead author, surmises that the physicians might have been focused on other clinical indicators that did have incentives attached to them.

She says that there was “a year-on-year fall-off in performance of about 3 percent in screening for diabetic retinopathy and a 1.6 percent fall-off for cervical cancer screening. Although it doesn’t seem like too much of a drop-off, keep in mind that these are real people who were not having cervical screenings or not having eye examinations if they had diabetes.”

She points out that the Kaiser incentives were given to the organization, not to the individual physicians, so the “incentives did not financially benefit the physician directly.” She says the findings show the need to continue to monitor performance, especially after incentives are removed.

Performance levels fluctuate as payment is instituted

Source: Lester H, Selby J, Fireman B, Campbell S, et al. “The impact of removing financial incentives from clinical quality indicators: longitudinal analysis of four Kaiser Permanent indicators.” BMJ; 2010;340:c1898

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.