Medical homes and accountable care organizations have a much greater chance of succeeding if physician pay is tied to performance, according to what is described as the first large-scale study of commercially insured patients to look into the matter.

“Although there is a good deal of evidence about variability in costs under Medicare, little has been published about the variability of costs for care that is financed by private insurance,” says a study in the September issue of Health Affairs, “Wide Variation in Episode Costs Within a Commercially Insured Population Highlights Potential to Improve the Efficiency of Care.”

That’s not all that it highlights. Doctors who meet quality and efficiency benchmarks provide care at costs that are 14 percent lower than costs for other doctors in the assessment program.

The study ( looks at 250,000 doctors who contract with UnitedHealthcare. It covers 21 different disciplines — including primary care, cardiology, and orthopedics — that account for more than 60 percent of the insurer’s employer-sponsored business. The analysis, for the most part, reflects care delivered in 2007 and 2008.

“For that period, 43 percent of the evaluated physicians received both the quality and cost-efficiency designations, and 14 percent received the quality designation only.” There were other categories as well, but the main point is that the doctors given quality and cost-efficiency benchmarks saved the plan money.

“Those distinctions in performance translate into meaningful differences in the care that patients receive. For example, cardiologists implanting arterial stents who have a quality designation had 55 percent fewer redo procedures — that is, stent replacements — and a 55 percent lower complication rate for those procedures than other cardiologists.”

The authors say the findings could influence “a wide range of payment reform initiatives, including primary care medical homes seeking to coordinate their patients’ care more effectively and receive bonuses tied to their quality and efficiency; accountable care organizations that take an additional responsibility for the quality and total costs of care and for population health; and, obviously, episode-based payment approaches.”

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.