MANAGED CARE April 1998. ©1998 Stezzi Communications

Welcome to the job: Less than a week after Norman Payson, M.D., took over as chief executive officer of Oxford Health Plans, the once high-flying HMO announced plans to pull out of the Medicaid business in Connecticut and New Jersey and to subcontract Medicaid operations in Pennsylvania. Meanwhile, Oxford's legal woes broadened with separate lawsuits by Connecticut and 10 medical societies for problems stemming from the company's now-notorious financial and information systems mess.

Oxford's withdrawal from the Connecticut and New Jersey Medicaid programs affects 75,000 people. In Pennsylvania, the HMO will remain a player, but has turned over program management and payment of medical costs to Health Risk Management. In return, Oxford will pay the Minnesota-based company 97 percent of annual premiums.

In a pair of unrelated developments, Connecticut's attorney general has joined New York State's class-action lawsuit against Oxford, charging it with concealing the extent of its operating and financial problems. And 10 medical societies signed on to legal actions initially filed against Oxford by the New York County [that's the borough of Manhattan] Medical Society, alleging nonpayment of $140 million. Oxford claims that the figure is far less and that it is making progress in paying claims.

Oxford now has breathing room to continue that effort, as well as to retreat and retrench. The Texas Pacific investment group pumped $350 million into Oxford, with the promise of raising an additional $350 million for debt financing.

With a new management team and a fresh stash of cash at Oxford, physicians and benefits managers are wondering what the HMO will look like by the end of this year. Texas Pacific's move cooled rumors that Payson's orders were to shape up the HMO for a sale, possibly to Aetna U.S. Healthcare — rumors fueled by Payson's record. Payson sold his own company, Healthsource, to Cigna last year when it ran into troubles similar to those Oxford now faces.

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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.