The judge who recently ruled in favor of UnitedHealth Group in a massive class-action suit that has been dragging through the courts since 1999, presented the state of the country's health coverage system as a somewhat dichotomous mess. "Those desiring changes in the way health care is provided in America must either look for remedies before Congress or allow the free market to dictate the results," wrote U.S. District Judge Federico A. Moreno, of the Southern District of Florida.

In fact, Moreno wrote that "no reasonable juror could return a verdict in the plaintiff's favor" and that there was insufficient evidence that the two health insurers were guilty of "agreeing with their competitors to defraud the doctors."

Moreno made the pronouncement on June 19, when he dismissed all claims that remained against UnitedHealth and Coventry Health care. This is the latest installment of a class-action suit filed by 700,000 physicians who charged that numerous health plans colluded to not pay them or to pay them too late and/or too little. The other plans involved (deep breath!) — Aetna, Anthem Blue Cross and Blue Shield, Cigna, Health Net, Humana, PacifiCare Health Systems, Prudential Financial Securities, and WellPoint Health Networks — had previously settled for a combined $646 million.

UnitedHealth, and the much smaller Coventry, were holdouts. "After reviewing thousands of documents, there is simply insufficient evidence of the wrongdoing claimed," Moreno wrote.

As the Wall Street Journal puts it: "The motion was a victory for UnitedHealth, whose board and management have come under fire in recent months over the pricing and timing of stock options granted to Chief Executive William McGuire and other top executives." The Securities and Exchange Commission has begun an inquiry, the article notes, and UnitedHealth's shares are down nearly 30 percent this year.

McGuire issued a statement. "We are pleased with today's decision. Looking ahead, UnitedHealth Group will continue to focus on our overarching goal: workings constructively with physicians and other partners to provide all Americans with greater access to affordable, quality health care."

However, it may not yet be over, says Archie Lamb, co-lead lawyer for the doctors. Health plans that have settled cannot be sued again. Not so with UnitedHealth, Lamb tells the Journal. "They may think they've won the war, but it is only a battle."

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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.