Several large HMOs that have experienced financial turmoil in recent times appear to be either recovering or downright healthy. Earnings for Aetna U.S. Healthcare, the nation's largest HMO, rose 40 percent during the fourth quarter of 1998, while costs remained stable in its commercial lines and increased only moderately in its Medicare business. Aetna had spent 1997 and the early part of 1998 with a financial hangover dating to its 1996 acquisition of U.S. Healthcare.

Another for-profit giant, Oxford Health Plans, whose stock fell hard in 1997 and 1998, says it could return to profitability before the end of this year. Oxford's hopes for a comeback got a boost when more accounts than expected renewed in January. Oxford is re-entering the Medicare market, too, after a six-month suspension.

Humana ended a wild ride in 1998 by finishing $57 million ahead of the game. Earlier in the year, Humana shares tumbled 30 percent when its proposed merger with United HealthCare ran aground, following United's 11th-hour disclosure of its own financial woes.

Perhaps the most remarkable turnaround is occurring at Kaiser Permanente. Just two years after posting a stunning $270 million one-year loss, the nation's biggest not-for-profit HMO expects premium hikes and cost-cutting measures to push it back into the black. Kaiser Permanente predicts a 2-percent margin for 1999.

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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.