Ten HMOs, covering more than 500,000 members, are in serious danger of collapsing, according to Weiss Ratings Inc. Of the 10 HMOs all rated E-minus ("very weak"), two — PriorityPlus of California and Rio Grande HMO, of Texas — have over 100,000 members.

Weiss counts 14 health plans that have failed this year. Only one plan achieved Weiss's top rating of "A," Blue Shield of California. Three others earned A-minus ratings.

On the upside, Weiss says most larger health plans have returned to profitability, and the end of the industry's financial decline may be in sight.

Oxford Health Plans is a case in point, turning its first profitable quarter in two years. Cost-cutting helped Oxford post third-quarter net income of $28 million. Two days before its announcement, Oxford President William Sullivan resigned to "pursue other interests." Sullivan was the last senior manager left from the HMO's heyday, which ended on an October 1997 day that saw its stock plummet 62 percent in a single trading session.

The bleeding is almost over for Kaiser Permanente, which has lost half a billion dollars in the last two years. Kaiser posted a $29 million net loss for the third quarter, down from its $89 million third-quarter loss last year. The company says if its North Carolina and Northeastern operations — which are being sold — were removed from the equation, it would have turned a $107 million surplus.

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.