The idea of a class-action lawsuit against HMOs was given a boost by a recent decision in a federal district court in Florida. Meanwhile, the Blue Cross and Blue Shield Association has sounded the alarm that efforts to increase health plan liability may be launched in at least eight states.

In a Feb. 20 decision, U.S. District Court Judge Federico Moreno refused to dismiss claims in several 1999 lawsuits filed on behalf of health plan members against six health plans.

The six are Aetna, Health Net, Cigna, UnitedHealth Group, Humana, and PacifiCare Health Systems.

The suits allege that plans used financial incentives for physicians that ultimately led to denials of care.

In his 45-page decision, Moreno threw out racketeering claims by 10 of the 16 plaintiffs, allowing six to proceed.

Claims against the health plans for breach of fiduciary duty were also allowed to be pursued.

The suits claim that the companies' gag clauses prevented physicians from explaining all the treatment options and how managed care companies do their jobs.

Richard Scruggs, the plaintiffs' lawyer, says that Moreno's ruling was a significant setback for managed care.

"The industry has been gloating that all these cases were going to be dismissed," he told the Wall Street Journal. "This was a major victory for subscribers to HMOs."

The American Association of Health Plans doesn't see it that way, noting that Moreno dismissed more than half of the cases. MCOs pin the blame for any consequences resulting from incentives on employers, who chose the benefit design.

Moreno's next decision is whether to allow the suits to proceed as class actions.

In the same month, the Blues released "Health Care and Insurance Issues: 2001 Survey of Plans," a report that says that several states are likely to seek expanded HMO liability this year.

However, Susan Laudicina, director of state service research for the Blues and the study's author, hastened to add that such efforts will face tough opposition. She told Business Insurance that although nearly half of the states considered expanding liability, only four actually passed such legislation.

Managed Care’s Top Ten Articles of 2016

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.