Two Blue Cross plans in Pennsylvania are regrouping after separate legal actions.

In Philadelphia, Independence Blue Cross has been ordered to stop a contracting practice that competitors said gave it an unfair advantage, and that hospitals complained hurt their bottom lines. The state insurance department told Independence it could no longer write "prudent buyer" clauses into hospital contracts. The clauses mandate that if a hospital signs a contract with another payer for rates that are lower than those negotiated with Independence, the hospital must offer that lower rate to Independence as well.

The state's action grew out of a lawsuit by QualMed, a Foundation Health Systems subsidiary that for years has tried to loosen the hold that Independence Blue Cross and Aetna U.S. Healthcare have had on the Philadelphia market. Together, the two companies account for more than 80 percent of the area's health insurance enrollees.

Meanwhile, the Health and Human Services inspector general has fined Blue Cross of Northeastern Pennsylvania $250,000 for failing to provide Medicare benefits to 5,000 subscribers. The insurer admitted the error but characterized it as a misunderstanding.

The company signed up new enrollees based on promises of specific vision care, dental and pharmacy benefits, but waited for written approval from the Health Care Financing Administration to deliver the benefits. HCFA assumed the benefit plan was already in place. In addition to the fine, Blue Cross of Northeastern Pennsylvania has paid more than $200,000 to subscribers to compensate for unpaid claims.

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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.