Two roads diverged in a lawsuit and Aetna and Cigna took the one less traveled by.

Ok, Robert Frost probably would not find much to inspire him in a lawsuit that about 600,000 physicians have filed against some of the biggest health plans in the country, but maybe John Grisham would. And both sides are definitely seeking poetic justice, especially in light of the U.S. Supreme Court's refusal last month to hear an appeal by the health plans to stop the class-action suit.

The court's action, or inaction, means that the 11th Circuit U.S. Court of Appeals ruling last September will stand. And the lower court said that the class-action suit can proceed.

The health plans had argued that the individual contracts the physicians had signed were so varied that it made a class action not practicable.

The physicians say that from 1990 to 2002 insurers programmed their computers so that the machines automatically underpaid doctors for services.

Named in the suit are Humana, PacifiCare, UnitedHealthcare, WellPoint, Anthem, and Health Net.

Aetna and Cigna had also been named but decided to settle out of court in 2003 for about $1.1 billion.

Yes, that seems steep, even by the standards of American industry. But now some suggest that a court ruling against the remaining HMOs would be even more costly.

The Blue Cross and Blue Shield Association, which faces similar provider lawsuits, tells Bloomberg News that the top court's decision "places heavy pressure" on the six health plans to follow Aetna and Cigna's lead and settle out of court "rather than roll the dice and possibly incur potentially crippling — even bankrupting — damages awards."

Meanwhile, both sides have not been idle while waiting for the Supreme Court's decision. They have been preparing for trial, and now they have a tentative start date.

U.S. District Judge Federico Moreno in Miami says that he will hear the case on Sept. 6. He had originally planned to begin in March. Stay tuned.

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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.

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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

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