The ink barely dry on its merger termination agreement with Health Systems International, Wellpoint Health Networks has acquired the health insurance business of Massachusetts Mutual Life Insurance Co.

Company officials say the deal, valued at $380 million, is "a key element in Wellpoint's expansion program."

Wellpoint's acquisition of the Group Life and Health subsidiary adds about 1 million to its membership roster. Group Life and Health is licensed to do business in 48 states, but its core operations are clustered in the most populous states.

Almost a year ago, Wellpoint announced its intent to merge with Health Systems International and create the largest publicly traded HMO. But as the deadline loomed, no final agreement between the two companies could be ironed out. Reportedly, discussions broke down when Wellpoint Chairman Leonard Schaeffer and Health Systems CEO Malik Hasan, M.D., could not agree on dividing control of the new company.

For the third year in a row, Blue Shield of California is reducing overall reimbursement rates for physicians and medical services. The cuts will average 5 percent. Since the nonprofit company adopted a resource-based relative value scale in 1994, reimbursement fees have been altered to follow Medicare fees.

Company spokesman Mike Odom says the cuts will mainly affect procedure-based services such as surgical, diagnostic and laboratory work. Payment for consultation and evaluation services will be increased by 2.5 percent. Reimbursement for Ob/Gyn services will remain about the same.

Blue Shield of California says physicians who contract with the company have agreed to the adjustments.

Last November, Louis Harris and Associates asked 1,000 Americans for their views on nonprofit and for-profit HMOs and hospitals. Respondents were split about which system is better able to deliver high-quality care at a reasonable price. But nonprofits were decisively hailed as good for the community.


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.