The Texas attorney general's decision in the Aetna case is the latest in a long string of events that has gutted the fundamentals of managed care. Many in health care think that some or all of these developments — taken together — have stripped health plans of their ability to manage care effectively.

April 2000 -- Texas settles lawsuit against Aetna U.S. Healthcare; insurer agrees not to give financial incentives to physicians for limiting care.

November 1999 -- United HealthCare says it will stop requiring preauthorization for most treatments.

April 1999 -- U.S. Fifth Circuit Court of Appeals says members may take HMOs to state court, upholding Texas's liability law.

April 1999 -- California judge upholds $120 million jury verdict against Aetna U.S. Healthcare in David Goodrich case, calling award high but not excessive.

January 1999 -- InterStudy Publications reveals that less than 1 percent of HMOs are staff-model. The number of staff-model plans — Paul Ellwood's vision of managed care — is down to eight, after 10 folded in 1998.

1998–1999 -- Among workers with employer-sponsored coverage, the share enrolled in HMOs drops, for the first time, in 1998. By 1999, PPOs enroll 43 percent of workers who obtain coverage through employers.

August 1998 -- Texas orders Harris Methodist Health Plan to pay $3.4 million to physicians whom the HMO fined for exceeding pharmacy budgets.

September 1997 -- Kaiser Permanente, Group Health Cooperative, and HIP Health Plans, plus two consumer groups, call for federal enforcement of 18 patient-protection principles — the impetus for the Patients Bill of Rights.

September 1997 -- Texas's first-in-the-nation HMO liability law takes effect.

August 1997 -- New Jersey law requires HMOs in the state to offer a point-of-service option. Nationally, point-of-service plans flourish; Barents survey says 92 percent of people with employer-sponsored coverage have option to choose plan that allows choice of out-of-network physician.

January 1997 -- Federal law mandating 48-hour hospital stays for mothers and newborns takes effect.

1995 -- Maryland, New Jersey, Massachusetts, and North Carolina become first states to pass laws prohibiting "drive-through" deliveries.

1994 -- Maryland law is first to designate Ob/Gyns as primary care physicians, starting open-access trend.


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.