Democrats in the California Senate last month killed Republican Gov. Pete Wilson's plan to overhaul managed care regulation. On a party-line vote of 22-15, the Senate rejected a plan to create a Department of Managed Health Care, which means that managed care oversight will remain with the Department of Corporations.

Sen. Herschel Rosenthal, a Los Angeles Democrat, said Wilson's plan "offered a Band-Aid solution" to a health system in need of major surgery. At the center of the dispute is what type of regulatory body will oversee California's $50 billion managed care industry. Health insurers in the state have tended to support proposals that keep regulatory control under the state's Business, Transportation and Housing Agency. The agency includes the Corporations Department and would have included the new managed care department. Rosenthal has criticized the agency, saying that it has shown "more concern for the financial health of HMOs than for the medical health of consumers." Consumer groups are pushing for a regulatory body with a greater public-health emphasis. Republicans have attacked that approach, saying it gives more power to "health bureaucrats."

Major managed care reform has moved slowly in California. For several months last year and earlier this year, Wilson refused to sign any reform measure, pending the report of a task force he and the legislature appointed to study the issue. Unless the legislature reaches a last-minute compromise this month, the issue will probably remain unresolved until Wilson's successor takes office next year.

Among the reform proposals under consideration is a bill passed by the Assembly, and now awaiting Senate action, that would allow HMO members to sue plans for medical malpractice.

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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.