For the second straight year, California Gov. Pete Wilson cited the prospect of rising health costs as he vetoed a host of managed care reform bills passed by the state legislature.In the weeks after the end of the legislative session, Wilson vetoed seven managed care reform bills, including three that would have tightened regulation of utilization review procedures.

All three proposals would have required that UR decisions be made by physicians licensed in California. One of the measures would have required HMOs to re-examine gravely ill patients before denying payment for services recommended by the patients' physicians.

Wilson rejected the most far-reaching of the bills as "a transparent effort to eliminate the appropriate use of utilization review and a bald attempt to increase the number of lawsuits in the health care system."

He also vetoed a bill that would have created a consumer commission to oversee managed care plans and one that would have required physicians and health officials to report HIV cases to the state using an anonymous coding system.

Last year, Wilson vetoed eight HMO bills on a single day, in a move that came to be known as the "Columbus Day Massacre." This year's vetoes came over a two-week period in late September.

Business groups welcomed the vetoes, claiming that every 1 percent increase in health insurance rates would push 40,000 people into the ranks of the uninsured.

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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.