Managed Care - January 2008 - (Page 31) leading care management programs. Predictive modeling software also is improving, although its information sources — claims, pharmacy, and occasionally laboratory data — have not changed in years. A few leading care management approaches are adding information from electronic health risk appraisals, however. As new sources of data become available, including the electronic medical record and the HIPAAcompliant electronic claim attachment, the capabilities of these systems are expected to leap forward. Pay for performance, in which some portion of financial incentives is aligned with the practice of evidence-based clinical care, continues to grow. P4P programs began in HMOs, but regional and national companies are now using them in PPOs. Studies are appearing that either support or play down the utility of P4P. In fact, both proponents and detractors of P4P often cite the same studies to make their arguments. The effect of P4P remains ambiguous. Nevertheless, most of the leading payers, as well as many large employers and CMS, are committed to P4P and programs continue to evolve. Perspective The importance of a new challenge or opportunity is not always immediately clear. Ten years ago for example, the emergence of large, integrated-provider networks assuming global risk for medical expenses, especially in Medicare, was viewed as a leading issue. Now, with a few exceptions, most have disappeared, having incurred stunning financial losses. Other examples — point-of-service plans and even capitation, for instance — did indeed assume a significant place in the landscape, but their importance or complexity has diminished over time. One constant: Costs continually increase. It is naïve and simplistic, as well as simply wrong, to try to blame one particular sector — whether physicians, hospitals, payers, drug companies, the government, or even our own unhealthy behaviors — for spiraling health care costs. The fact is that most of us remain able to afford these cost increases, and none of us are willing to forgo the best possible care, at least if we have insurance coverage. But for how long will that be the case? With rising numbers of uninsured and with small employers bailing out of health insurance, combined with an increasingly aggressive political climate, could significant changes to the health insurance industry be in store? Never say never, ever. MC JANUARY 2008 / MANAGED CARE 31
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