A subsidiary of Aetna U.S. Healthcare is the first HMO to face a malpractice lawsuit under a recently enacted Texas law. The suit against NYLCare of Texas was filed by the family of a 68-year-old Fort Worth man who committed suicide by drinking antifreeze hours after being discharged from a psychiatric hospital over his physician's objections.

The suit alleges that NYLCare denied the man adequate hospital care despite his suicidal impulses and his physician's advice to the contrary. According to the lawsuit, the patient, a retired pharmacist, "used up his days according to whatever cookbooks or protocols for psychiatric treatment" NYLCare used. The suit asserts that the plan's systems increased the chance that substandard care would be delivered.

The HMO says it will defend itself vigorously.

Under Texas law, an injured consumer can sue a health insurer if he or she was hurt by the insurer's delay or denial of treatment. Missouri is the only other state to allow such suits, though Pennsylvania may join them soon (see item at right).

After Texas passed the HMO liability law last year — and before Aetna bought NYLCare — Aetna challenged the law in federal court. District Judge Vanessa Gilmore upheld the law Sept. 18. A few days before the family filed its suit, Aetna said it would appeal Gilmore's decision. The appeal will be heard by the U.S. Circuit Court of Appeals in New Orleans.

Also in Texas, outgoing Insurance Commissioner Elton Bomer scrapped plans to publish formal state guidelines for physician payment by HMOs.

Bomer, leaving next month to become a senior adviser to Gov. George W. Bush, said the state will enforce, on a case-by-case basis, a 1997 law that bars HMOs from using financial incentives to limit services. A task force couldn't agree on the percentage of a physician's compensation that should be at risk in an HMO contract.

HMOs wanted 25 percent, while consumer groups wanted to limit physicians' risk to 10 percent of compensation.

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.