John Marcille

Accountable care organizations (ACOs) promise a reconfiguration of delivery with the provider at the center of operations. The Centers for Medicare & Medicaid Services (CMS) has about 250 ACO contracts, as our cover story points out.

Author Peter Wehrwein reports that health plans for the most part are on board, participating in ACOs outside of the CMS demos in a big way and really trying to make a go of this thing.

To do that, though, the interaction between plans and providers will need to be more collaborative — in fact physicians will need help, something the insurers already offer.

“ACO payment mechanisms and financial incentives aren’t going to magically transform physicians and the way they practice medicine,” Jill Hummel, vice president for payment innovation at WellPoint, tells Wehrwein. The technology has evolved. In video game parlance, it’s the difference between “Super Mario Brothers” and “Call of Duty.”

WellPoint offers care management services to small practices on request. It also offers free access to the American College of Physicians’ “Medical Home Builder,” an online toolkit and resource center. “We have to get physicians off the fee-for-service treadmill,” says Hummel.

With great power comes great responsibility, and that means more work for physicians. Will they have the time?

“That’s a good question,” says Barry Newman, MD, the CMO at Westmed Medical Group, a 250-doctor multispecialty group. “That is why we have invested in additional resources like analytics to automate as much as possible and hired case managers, physician extenders, and other additional staff.”

The goal, he says, is to transfer as much work as possible from physicians so they can focus on critical evaluation and treatment decisions that require the expertise of a physician.

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.