John Carroll

John Carroll

The Anthem-WellPoint merger is a done deal, thanks to buyer Anthem's generous offerings to two states whose approvals were needed to create the largest health insurer in the country. The merged entity, to be called WellPoint and have headquarters in Indiana, will have 28 million members in 13 states.

Anthem chairman Larry Glasscock will serve as CEO of the new company, with WellPoint's CEO Leonard Schaeffer becoming the chairman. "This merger is a great strategic and geographic fit," Schaeffer tells the Los Angeles Times.

It certainly appears to be a great fit for California and Georgia.

When California insurance commissioner John Garamendi backed off his heated opposition to the Anthem-WellPoint merger, he left with a smile, carrying off some $265 million in pledges from the managed care giant for programs that catered to the uninsured and underserved areas of the state.

The charitable contributions he wrangled from the deal include $35 million for health care clinics, $15 million to provide coverage for uninsured children, and $15 million to cover the cost of a training program for new nurses — all on top of $200 million over 20 years for programs to enhance health care quality.

Three days after the California settlement was announced in mid-November, Georgia Insurance Commissioner John Oxendine concluded that the citizens of his state "deserved better." And if Anthem wanted his blessings on the deal — which includes Blue Cross and Blue Shield of Georgia — he told reporters, it would required some "sweetening."

On November 30, Oxendine approved the deal after Anthem agreed to provide a total of $126.5 million for health care programs in his state. Georgia for the next 20 years will receive 2 percent of the Anthem investment stock portfolio to buy bonds to expand and improve rural health centers in the state, according to the Wall Street Journal.

Anthem expects to build telemedicine centers at 36 rural hospitals and clinics in the state. "It is vitally important to our state to ensure that our rural citizens have equal access to the best possible health care," Oxendine tells the Atlanta Journal-Constitution.

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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.