MANAGED CARE February 1998. ©1998 Stezzi Communications

Troubles continue for Oxford Health Plans, the one-time high-flying HMO whose stock has lost three quarters of its value since October. New York's insurance department fined the company $3 million for violating regulations, including the HMO's failure to pay claims on time. Oxford agreed to pay another $500,000 in restitution to customers, physicians and other providers.

Oxford violated state laws by issuing contracts that had not been state-approved, regulators said. It used contracts with rates other than those on file with the department, and wrongly denied valid claims.

New York regulators also forced Oxford to establish internal procedures to generate reliable data for claims, premiums and expenses; evaluate and beef up senior management, and hire an outside consultant to evaluate its information systems, internal controls and management reporting.

Oxford is looking for a CEO to replace William Sullivan, 34, who took the helm last summer. The HMO also appointed Albert Koch, known as a turnaround specialist, as temporary chief financial officer. Former CFO Andrew Cassidy left Oxford shortly after it reported a $78 million third-quarter loss, causing its stock to plunge.

Connecticut's insurance department will audit the company either this or next month, in response to a local medical group's concerns about Oxford's financial status. And the HMO faces at least six lawsuits from stockholders who argue that the company failed to disclose all it knew about its deteriorating financial situation.

Oxford covers 1.9 million people in New York, New Jersey, Pennsylvania, Connecticut, New Hampshire, Florida and Illinois.

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.