For all the talk of change in the state of California's ability to govern health care delivery, it appears that one group — physicians — is falling through the cracks.

California passed a series of health care reform bills last year, including a measure that established a Department of Managed Care to oversee health plans operating in the state. Passage of 21 new laws coincided with an unrelated series of medical group failures that physicians nonetheless blamed in part on MCOs' rules of engagement.

But while the new Department of Managed Care is talking tough about patient protections, medical groups have been left to sink or swim. The most recent evidence may be embodied in KPC Global Care, the company formed from most of the assets of MedPartners' California provider network. KPC, which operates 42 clinics and serves a half million patients, is losing $2 million a month and is delaying some payments to physicians and suppliers, the Los Angeles Times reported. KPC's owner says his company can survive only two to four more months without receiving higher payments from health plans.

The Department of Managed Care, which assumed oversight of HMOs from the Department of Corporations on July 1, has offered little in the way of protection for physician groups. It can ask some groups to prove they are solvent, but some observers feel it could take up to two years before the department can establish regulations for medical groups. In the meantime, the state remains as hands-off with physician groups as it ever was.

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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.