MANAGED CARE May 1998. ©1998 Stezzi Communications

Aetna's announcement that it would purchase the health care operations of New York Life Insurance Co. wasn't much of a surprise, but it sparked concern on Wall Street and in doctors' offices. The $1 billion merger transfers the care of 2.2 million people--1.5 million of whom are enrolled in New York Life's managed care unit, NYLCare — to Aetna. Aetna U.S. Healthcare thus becomes a stronger player in several markets, particularly Texas and the Baltimore-Washington area.

Several credit services placed Aetna's ratings under review, citing the company's difficulty digesting its 1996 acquisition of U.S. Healthcare. But analysts are optimistic that Aetna's plan to blend NYLCare into its operations more slowly than it did when it bought U.S. Healthcare will prevent a replay of the difficulties experienced with the earlier merger.

Physicians are concerned that the deal will be a raw one for them once Aetna U.S. Healthcare assumes management of NYLCare enrollees. While NYLCare has a good reputation with doctors in Texas, physicians there have been at war with Aetna U.S. Healthcare over what they consider low compensation and burdensome contract terms.

The move may set the stage for an all-out shootout between Texas physicians and Aetna U.S. Healthcare. Fed up with what they consider take-it-or-leave- it contracts, a number of physician groups in the state have walked away from the HMO when time has come to re-up. The situation got more play when Methodist Hospitals of Dallas terminated its relationship with Aetna U.S. Healthcare April 20 over delayed payments and what it called "annoying requests for documentation."

Acting on complaints from physicians in Texas and other states, the AMA sent Aetna U.S. Healthcare a letter protesting what it called contracts of adhesion and interference with medical decisions. In a point-by-point response, Aetna denied offering contracts of adhesion ("No one is forced to sign," the company said in a statement) and said that physicians are being held accountable for their own decisions.

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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.