Efforts by two Blue Cross plans to reshape themselves in opposite directions have hit the same wall: rejection by state regulators. Blue Cross Blue Shield of Massachusetts hoped to split itself into three companies; its counterpart in Texas wanted to merge with Blue Cross Blue Shield of Illinois and possibly with other Blue Cross plans. Regulators in Boston and Austin nixed the separate proposals.

Texas Blue Cross argued that its merger with the Illinois plan, first announced in 1996, would create a company large enough to compete against for-profit giants being created by deals most recently typified by United HealthCare's merger with Humana and Aetna U.S. Healthcare's purchase of New York Life's health insurance business. Texas Attorney General Dan Morales challenged the Blues deal in court, arguing that it would result in Texas policyholders' money going to Illinois. A state judge rejected Morales' legal arguments, and the deal remained in limbo until state regulators weighed in.

Meanwhile, Massachusetts Commissioner of Insurance Linda Ruthhardt rejected a proposal by that state's Blue Cross plan to split itself into a tax-exempt HMO, an administrative services company and an indemnity health insurance company. The commissioner indicated in a letter to the company that it could reapply for the reorganization once the Internal Revenue Service resolves the tax status of the companies that would be created. But she asked that any reapplication include full financial information for 1998, which means that Blue Cross can't seek approval again until next year.

Ruthhardt last month also ended daily monitoring of the company's finances. She ordered the scrutiny last year because the plan was losing millions of dollars each month.

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.