A federal judge has blocked the proposed $54 billion merger of two major health insurance companies, Anthem and Cigna, after the Justice Department concluded that the deal would reduce competition in the health insurance market and raise prices.

Judge Amy Berman Jackson of the U.S. District Court for the District of Columbia made the ruling.

Anthem is determined to ensure Wednesday’s decision isn’t the final word on the issue. The company said in a statement Thursday that it “promptly intends to file a notice of appeal and request an expedited hearing.”

The Justice Department announced last summer that it would oppose both the Anthem-Cigna merger and one by Aetna and Humana, These are four of the major five insurers in the nation.

Both mergers have now been blocked in separate federal court cases citing adverse effects on competition and pricing.

Then-Attorney General Loretta Lynch said: “If allowed to proceed, these mergers would fundamentally reshape the health insurance industry. They would leave much of the multi-trillion dollar health insurance industry in the hands of three mammoth insurance companies, drastically constricting competition in a number of key markets that tens of millions of Americans rely on to receive health care. … If these mergers were to take place, the competition among these insurers that has pushed them to provide lower premiums, higher quality care and better benefits would be eliminated.”

The California Insurance Commissioner said “Today’s federal court decision to block the merger of two of the nation’s largest health insurers is a significant win for consumers who need more choice, not less, in an already highly concentrated health insurance market. Bigger was definitely not better when it comes to the Anthem-Cigna merger.”

“Last year I held an extensive public hearing on the proposed merger. After reviewing all the evidence, I concluded the Anthem-Cigna merger was bad for consumers and businesses, and bad for health insurance and health care markets. I issued detailed findings of fact and law and urged the U.S. Department of Justice to sue to block this merger because it is anti-competitive and would harm California consumers, businesses, and the California health insurance market.”

The commissioner concluded that “Allowing a merger between two of the largest health insurers in the country would have increased the price of health insurance, and decreased choice and the quality of healthcare for consumers and businesses. I am very pleased the federal district court entered a decision consistent with my findings and legal conclusions that the Anthem-Cigna merger is anti-competitive.”

The long arm of the pharmaceutical industry continues to pervade practically every area of medicine, reaching those who write guidelines that shape doctors’ practices, patient advocacy organizations, letter writers to the Centers for Disease Control and Prevention and even oncologists on Twitter, according to a series of papers on money and influence published in JAMA Internal Medicine and an article on NPR.

Researchers Ray Moynihan and Lisa Bero wrote in an accompanying commentary that the “very way we all think about disease – and the best ways to research, define, prevent, and treat it – is being subtly distorted because so many of the ostensibly independent players, including patient advocacy groups, are largely singing tunes acceptable to companies seeking to maximize markets for drugs and devices.”

More than two-thirds of patient advocacy organizations that responded to a survey indicated that they had received industry funding in their last fiscal year. For most, the money represented a small share of their budget. But 12 percent said they received more than half of their money from industry.

US Centers for Disease Control and Prevention ( CDC) recently developed guidelines for prescribing opioids for chronic pain. When the draft guidelines were released , there was criticism. Some organizations argued that the development of the guidelines was not transparent and the recommendations were based on weak evidence. Subsequently, the CDC postponed the release of the guidelines and opened them to public comment for a 30-day period.

Researchers Moynihan and Bero analyzed these comments to identify levels of support for the guidelines and whether financial relationships with opioid manufacturers were associated with opposition to the guidelines. The final guidelines were released in March 2016.”

158 organizations formally submitted comments after the proposed guidelines were released in February 2016, and 80 percent of them were supportive, though some had recommendations for changes. Organizations that received funding from opioid manufacturers were less supportive of guidelines proposed by the CDC to limit prescribing of the drugs for chronic pain.

Of the 158 organizations, 45 (28.5%) received funding from opioid manufacturers, 25 (15 .8%) had funding ties to other companies in the life sciences, 64 (40.5%) received no funding from the life sciences industry, and funding of the remaining 24 (15.2%) was not known. Of the organizations that received funding from opioid manufacturers, none disclosed these funding sources in their comments; of the organizations that received funding from the life sciences industry, 6 (24%) disclosed their funding.

Fifty-two organizations (32.9%) were supportive of the guidelines without additional recommendations, 75 (47. 5%) were generally supportive with recommendations, 18 (11.4%) were generally not supportive with recommendations, and 13 ( 8.2%) were not supportive.

Opposition to the guidelines was more frequent among organizations with funding from opioid manufacturers than those without funding from the life sciences industry, both overall and for recommendations about limits on opioid dosing and the length of opioid treatment.

Among the 45 groups that received money from opioid makers, though, the level of support was only 62 percent. And none of those groups disclosed their funding sources in their comments. (The CDC did not ask or require them to do so.)

“More people are dying than ever before from these products, and it’s important to know how the market is shaped by the spending of drug companies,” G. Caleb Alexander, co-director of the Center for Drug Safety and Effectiveness at Johns Hopkins 1University, said in an interview.

TeamHealth Holdings, Inc. is one of the nation’s largest providers of outsourced physician staffing solutions for hospitals. The company contracts with hospitals and physician groups in the areas of emergency medicine, hospital medicine, anesthesia and specialty hospitalist services. It also offers combined outsourcing services to single hospitals and hospital systems

TeamHealth has a growing presence in California. In 2014 it announced the acquisition of the operations of Burbank, Calif.-based Primary Critical Care Medical Group (PCCMG). Specializing primarily in hospital and critical care medicine, PCCMG provides clinical services through partnerships with four hospitals and two outpatient primary care clinics in the Southern California market.

IPC Healthcare Inc., was purchased by TeamHealth in November 2015. IPC is headquartered in North Hollywood, on Lankershim Boulevard. IPC manages hospitalist practice groups in the San Francisco Bay Area and the Inland Empire, and nationally. The transaction was valued at approximately $1.6 billion.

TeamHealth’s approximately 10,000 affiliated healthcare professionals provide emergency medicine, hospital medicine, anesthesia, urgent care, and pediatric staffing and management services to approximately 900 civilian and military hospitals, clinics, and physician groups in 46 states.

The Department of Justice just announced that TeamHealth Holdings, as successor in interest to IPC has agreed to resolve allegations that IPC violated the False Claims Act by billing Medicare, Medicaid, the Defense Health Agency and the Federal Employees Health Benefits Program for higher and more expensive levels of medical service than were actually performed (a practice known as “up-coding”). Under the settlement agreement, TeamHealth has agreed to pay $60 million, plus interest.

The government contended that IPC knowingly and systematically encouraged false billings by its hospitalists, who are medical professionals whose primary focus is the medical care of hospitalized patients. Specifically, the government alleged that IPC encouraged its hospitalists to bill for a higher level of service than actually provided. IPC’s scheme to improperly maximize billings allegedly included corporate pressure on hospitalists with lower billing levels to “catch up” to their peers.

As part of the settlement, TeamHealth entered into a five-year Corporate Integrity Agreement (CIA) with the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) covering the company’s hospital medicine division. This CIA is designed to increase TeamHealth’s accountability and transparency so that the company will avoid or promptly detect future fraud and abuse.

The settlement resolves allegations filed in a lawsuit by Dr. Bijan Oughatiyan, a physician formerly employed by IPC as a hospitalist. The Act also allows the government to intervene and take over the action, as it did in this case. Dr. Oughatiyan will receive approximately $11.4 million from the settlement.

The fallout from the Aug. 26 signing of Assembly Bill 2883 eventually became the defining topic of discussion during the fourth quarter among insurance agencies, carriers and most notably business owners who now find it more challenging to exclude themselves from their own workers comp policies. Most industry insiders got their first heads-up in mid-October, just a couple months ahead of the Jan. 1 effective date.

According to the article in the Central Valley Business Journal, the legislation requires all officers, members and partners to be covered under the workers compensation policy unless more restrictive qualifications are met.

To compound the matter, language delaying the application of the bill for in-force policies was omitted from the text. This omission, coupled with the narrower definition of who can be excluded from coverage, caused a massive disruption for the industry as a whole.

If your business is set up as a corporation, you must be an officer or director owning at least 15 percent of issued and outstanding stock on Jan. 1, 2017 to qualify for exclusion.

You must also execute a waiver of your rights to workers comp coverage, certifying under penalty of perjury that you are a qualifying officer or director with the requisite stock ownership.

If your business is organized as a partnership or LLC, you must now be a general partner of a partnership or a managing member of an LLC to qualify for exclusion (no minimum amount of ownership required).

The bill was supported by the American Insurance Association and the Association of California Insurance Companies, who contended the election process for opting out of coverage was not clear and led to abuses of the system.

In a handful of cases, certain employers gamed the system by claiming that employees with no real stake in the entity were officers, then excluding them from coverage.

As is often the case, small to middle-market businesses are experiencing the most devastating impact of the new legislation. Previously excludable individuals are covered as of Jan. 1, and premium for those individuals is accumulating.

In the worst cases, owners who do not perform strictly office work are being assigned to more costly classification codes. Many small businesses are seeing premiums double now that key employees are no longer excludable.

At a minimum, employers who exclude individuals from coverage now have additional paperwork to file with insurance carriers. Some entities have convened roundtable discussions with their insurance agents, accountants and lawyers to restructure corporate shares or reorganize the business to accommodate for continued exclusion of key employees.

This was defense attorney Kimberly Allyson Hansen’s third discipline proceeding. It arises from her representation of two defendants before the Workers’ Compensation Appeals Board. The WCAB imposed sanctions against Hansen and three other attorneys from her law firm after concluding that they had intentionally misled the Board, causing it to take unwarranted action.

According to the 23 page State Bar Opinion (Designated for Publication) “At all times relevant to this matter, she worked as a vice-president at the law firm of Stockwell, Harris, Woolverton & Muehl and was an experienced workers’ compensation attorney.”

Louis Speight, an employee of Vulcan Materials Company, Western Division, submitted a workers’ compensation claim for work-related injuries. During the course of litigation, it took defense attorneys three attempts to obtain a QME panel. The Medical Unit denied the first QME Request “due to the lack of all necessary information.” The Medical Unit also informed Hansen that her first QME Request had been filed prematurely. Hansen was directed to “resubmit [her] request as soon as possible…” The Medical Unit notified Hansen it was rejecting her second request because it also lacked “all necessary information. ” One week later, on July 28, 2009, Hansen submitted a third QME panel request to the Medical Unit.

Between the second and third QME request, the Speight case was set for conference. The WCALJ overruled defense objections and set the matter for trial. But a defense Petition for Removal was granted on the issue of the QME panel. However defendants “failed to disclose to the WCAB that the Medical Unit had timely advised Hansen that the First and Second QME Requests were deficient.”

Three weeks after the Petition for Removal was filed and before the WCAB ruled on it, the Medical Unit issued a QME panel in response to Hansen’s third QME Request. “The WCAB granted the Petition for Removal on December 21, 2009, on the grounds that the ALJ should have ordered the matter off calendar to allow the Defendant to obtain a QME panel. Still, Hansen did not notify the Board that a QME panel had already been assigned three months earlier, and she again remained silent when the WCAB issued a second order on March 9, 2010, rescinding the ALJ’s trial-setting order and directing the Medical Unit’s Medical Director to issue a QME panel.”

Three weeks later, the WCAB learned of the true state of affairs when the Medical Director filed a verified Petition for Reconsideration, a Petition to Reopen the Record, and an Offer of Proof, which disclosed that the Medical Unit had in fact timely responded to Hansen, advising her that the First and Second QME Requests had been denied for procedural deficiencies and that the Third QME Request had been granted and a panel had been issued several months earlier.

The WCAB did not take lightly the fact that its orders to the ALJ to vacate the trial setting order and to the Medical Unit to issue a QME panel were based on “a distorted version of the record.” The WCAB concluded its hotly contested sanction hearing by saying the “problem was not that the attorneys zealously represented their client; it was that they did so by misleading the WCAB, by concealing material facts, and by supporting their position with half-truths.”

As a consequence of the WCAB’s actions, the Office of the Chief Trial Counsel of the State Bar (OCTC) initiated disciplinary proceedings against Hansen and her colleague Kevin White, an associate with the Stockwell firm, who attended a mandatory settlement conference. The hearing judge in the disciplinary matter determined against Hanson that “Hansen’s participation in the workers’ compensation case involved acts of dishonesty constituting moral turpitude. She further found three factors in aggravation (two prior records of discipline, significant harm, and lack of insight) and two factors in mitigation ( cooperation and good character).”

Both Hansen and the Office of the Chief Trial Counsel of the State Bar (OCTC) appealed. Hansen asserts that this case should be dismissed because she made no misrepresentations to the WCAB, but rather was merely zealously representing her clients. OCTC supports the hearing judge’s culpability findings, but requested a finding of more aggravation and less mitigation, and that after appeal there be a recommend disbarment.

Having independently reviewed the record it was found that “Hansen is culpable of acts of moral turpitude, in violation of Business and Professions Code section 6106.” However it agreed “with the hearing judge that an 18-month actual suspension is appropriate.”