A federal court in New Orleans has ruled that members may take their HMOs to state court if they are unhappy with their care. The decision, however, does not allow patients to sue over denials of coverage.A three-judge panel on the Fifth Circuit Court of Appeals said that Texas resident Bridgett Giles could sue NYLCare Health Plans in state court. Giles's son died after a physician failed to diagnose a heart condition. Aetna, NYLCare's parent, will appeal.

The court did not address its previous liability rulings, which prevent patients from seeking damages in coverage disputes — an area the court has said is off limits per the Employee Retirement Income Security Act. But the new judgment means that in Mississippi, Louisiana, and Texas, where Fifth Circuit rulings are law, patients can sue HMOs in state courts about care — an area traditionally governed by state-level regulation.

The ruling sets the stage for the HMO industry's appeal of Texas's unique right-to-sue law, which will be heard in the same federal court.

Meanwhile, a California judge has upheld a $120 million jury award against Aetna U.S. Healthcare in the David Goodrich case. San Bernardino Superior Court Judge Christopher Warner wrote that although he thought the damage award was "high," it was not "excessive."

And in an interesting twist in the liability tussle, the Illinois Academy of Family Physicians opposes a series of bills in the state legislature that would grant patient protections, including the right to sue HMOs. The bills are supported by the Illinois State Medical Society. IAFP thinks the bills would add bureaucracy and costs to health care.

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.