A key federal court ruling was expected at press time on a series of lawsuits against the HMO industry. Additionally, the nation's largest managed care operator reportedly is negotiating a settlement. The convergence may determine whether HMOs can put the worst of their legal issues behind them — or if the gates are opened wide for an onslaught.

Two years ago, lawyers who had brought the asbestos and tobacco industries to their knees set their sights on MCOs — filing more than a dozen suits on behalf of members. The suits against Aetna, Cigna, UnitedHealth Group, Humana, PacifiCare, and others differed, but the thrust of most was that HMOs created obstacles to needed care. Plaintiffs' lawyers are trying to have the suits certified as class action.

A judicial panel last October ordered that the suits seeking class-action certification be consolidated before being argued in U.S. District Court in Miami. There, Judge Federico Moreno last month heard arguments for class-action status. He is expected to rule shortly on whether to certify the suits — or dismiss them.

In a curious twist, at least one MCO, Aetna, is in settlement talks with several plaintiffs, even though the cases have not yet been certified as class-action suits. The Wall Street Journal quotes a lawyer close to the talks as saying that the discussions could bind Aetna to an agreement to end use of financial incentives that could inhibit access to care and drop use of clinical practice guidelines drafted by actuarial firms. The talks reportedly took on greater urgency as the Bush administration, which has said it favors passage of a patients-rights bill, settled in. Aetna did not comment on the report.

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.