In a stern warning issued to the health insurance industry, an Obama administration official says that the government won’t hesitate to block mergers that threaten to stifle competition. During a conference with the American Bar Association and the American Health Lawyers Association, Christine Varney, the Justice Department’s antitrust chief, said that enforcement of antimonopoly laws is vital to the success of the new health care law, especially in trying to control rising premiums.

Varney said that the antitrust division “is committed to vigorously, but responsibly, scrutinizing mergers in the health care industry that appear to present a competitive concern.” She added that if the department’s concerns are well founded, “we will not hesitate to block the merger or to require the settlement concessions necessary to protect consumers.”

The government’s scrutiny will not stop at insurers, however. Varney also put hospitals on notice that the government will investigate hospital mergers that are likely to reduce competition.

In typical finger-pointing fashion, groups representing doctors and consumers have protested mega mergers of insurers, blaming consolidation for rising costs. Insurers counter that larger companies save money by being more efficient administrators, and they fault doctors and hospitals for driving up medical costs by ordering too many tests and performing too many procedures.

Varney provided an example of the Justice Department’s strategy in a case study involving a recent merger proposal in Michigan between Blue Cross Blue Shield of Michigan and Physicians Health Plan. The Blues plan controls nearly 70 percent of the market, and Physicians has 20 percent. Varney noted that the competition between the two companies had led them to offer lower prices, better service, and more innovative products. In contrast, the merger would have given the Michigan Blues the ability to control physician payment rates “in a manner that could have hurt the quality of health care being provided.”

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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.