The consolidation of member plans in the Blue Cross and Blue Shield Association has hit yet another snag. The Kansas Supreme Court on Aug. 6 upheld an order blocking the $190 million sale of the not-for-profit Blue Cross and Blue Shield of Kansas to Anthem, a for-profit operation.

In making the decision, the court cites an independent review team's findings that the merger would raise premiums by $248 million over the next five years.

Though the insurers dispute that, they're not going to continue pursuing the sale because there's "no other legal recourse," Anthem spokesman Edward West tells the Indianapolis Star.

Anthem officials hasten to add that, though disappointed, the insurer will "continue to seek expansion through affiliations with other health plans."

BCBS of Kansas officials say they have no choice but to affiliate with a national health plan, and they'll keep trying. The plan covers about 400,000 enrollees.

"We've lost 80,000 members since December of 2001," Graham Bailey, BCBS of Kansas spokesman, tells the Wichita Eagle.

"The population is not growing, and some groups that we used to cover or were prospects for us have been merged or associated out of state. Our prospect is going down, our membership is going down, and that means fewer members to spread risk and administrative costs across."

There are four plans within the Blues that are for-profit, publicly traded companies: Cobalt, Anthem, WellPoint, and WellChoice. Anthem and WellPoint are two of the biggest health plans in the country. The Indianapolis Star describes Anthem as one of the handful of "aggressive Blues companies trying to buy smaller and often minimally profitable Blues plans and convert them from policyholder-owned companies into for-profit operations."

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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.