Managed Care
Susan Worley

Ella Kazerooni, MD

Screening rates for the deadliest of cancers have languished, but recent rulings by CMS and the U.S. Preventive Services Task Force mean nearly universal coverage for low-dose CT scans. The cost-effectiveness of this effort for payers will depend on skillful implementation.
Contributing Voices
Frank Diamond
Mehmet Oz - World Economic Forum Annual Meeting 2012

In the land of Oz, you can take a pill that makes you lose weight. In the land of Oz, endive, red onion, and sea bass decrease the likelihood of ovarian cancer by 75%. In the land of Oz, acupuncture can help patients stop smoking, lose weight, and even avoid colds.

Mehmet Oz, MD, a national talk show host started his career as one of the best heart transplant surgeons in the world, practicing at Columbia and New York-Presbyterian Hospital.

Now, he’s under fire for allegedly peddling quackery. Ten physicians wrote to Columbia on Wednesday demanding that the school cut ties with the celebrity doctor who, they wrote, “has manifested an egregious lack of integrity by promoting quack treatments and cures in the interest of personal financial gain.”  

Contributing Voices
Frank Diamond

There are few issues that unite the political polarities these day, but there seems to be consensus emerging about this: We dump too many people in prison, including dumping them on a former coal ash landfill, a situation sparking controversy in a corner of Pennsylvania.

Liberals might see overpopulated prisons as resulting from, say, police profiling, while conservatives might believe, for instance, that there are just too many nonsensical laws on the books. The bottom line: The United States imprisons more people than any other country.

State Correctional Institution (SCI) Fayette County in Pennsylvania, housing 2,000 prisoners and opening in 2003, rests on top of a former coalmine and next to a 500-acre coal ash dump in rural Luzerne township. Not good and possibly unconstitutional, charge two human rights organizations, the Abolitionist Law Center (ALC) and the Human Rights Coalition (HRC) in a recently issued study (

They cite the Eighth Amendment, which forbids cruel and unusual punishment, and building a prison on a “massive toxic coal waste dump” might be just that. Over 40 million tons of coal waste had been dumped on the site “at depths approaching 150 feet in some places.” The study states that, “Ash is regularly seen blowing off the site … and collecting on the houses of local residents as well as the prison grounds at SCI Fayette.”

News & Commentary
Better management of respiratory distress syndrome and broncho-pulmonary dysplasia is the main reason these tiny patients have a much better chance of survival than they did 15 years ago, according to researchers, who examined 6,075 deaths among 22,248 infants from 2000 to 2011.
News & Commentary
There’s uncertainty about how to manage these patients and not miss a life-threatening problem. Patients often can’t describe dizziness, say researchers, and those with syncope may not recall if they actually lost consciousness. There needs to be a clinical algorithm to determine just who should get a CT scan.
Legislation & Regulation
Richard Mark Kirkner

Ellyn Sternfield

What started out as a charitable campaign has morphed into a hospital and pharmacy enrichment scheme. There’s a lack of regulation and oversight. Think of it as a shell game. The more hands that move the drugs around, the more difficult accountability becomes.
Managed Care Outlook
The Catalyst for Payment Reform (CPR) reported that in 2013 just 11% of payment to providers was not under an FFS model. CPR’s second report card last year found that 40% of commercial health plan payments were made through payment methods designed to improve quality and reduce waste.
Contributing Voices
Peter Wehrwein

Sovaldi, Harvoni, Viekira Pak, a slew of oncology meds—they’re all contributing to specialty pharmacy sticker shock.

Ivacaftor (Kalydeco) for cystic fibrosis hasn’t been in the news quite as much, but priced at $300,000 per year, it’s also part of the trend of super-high-priced drugs that is sweeping American health care.

Approved by the FDA two years ago, ivacaftor targets a particular genetic mutation that affects only about 4% of people with cystic fibrosis, so despite that stratospheric price, it hasn’t had the same effect on budgets as the hepatitis C drugs like Sovaldi or, increasingly, expensive cancer drugs.

One of our regular contributors, Krishna Patel, wrote about ivacaftor in this month’s issue of Managed Care, and her takeaway was for payers to follow the guidelines for ivacaftor and not erect obstacles to people getting a drug that might make a huge difference in their lives.

But the FDA is expected to approve a new medication some time this year that combines ivacaftor with another medication, lumacaftor. And rather than working in small percentage of people with cystic fibrosis, this new combination is expected to be effective in roughly half of those with the cystic fibrosis who are ages 12 and older.

Kevin Bowen and Patrick Gleason of Prime Therapeutics are presenting a poster today at the annual meeting of Academy of Managed Care Pharmacy in San Diego that gives some estimates of the financial consequences of this new drug on health plans and other payers.

Managed Care Outlook
An announced overhaul of Medicare would mean that 30% of payments for fee-for-service beneficiaries would be funneled through alternative payment models by next year and 50% by 2018. The shift would rely on accountable care organizations, bundled payments, and medical homes. Can CMS pull this off?
Ibrahim M Abbass, RPh, PhD
Trudy M. Krause, DrPH, CPHQ
Salim S. Virani MD, PhD
J. Michael Swint, PhD
Length of stay is increasing, as is the utilization of imaging procedures. Nevertheless, transferring patients from the emergency department to the observation unit (OU) remains less costly than inpatient admissions. Researchers reached their conclusion after examining data on nearly 16,000 patients admitted to the hospital or OUs between January 2009 and December 2012.
Medication Management
Thomas Reinke
The legal challenges are underway, but it’s also increasingly difficult to estimate the economic impact of these medications. Much will depend on market penetration. Prime Therapeutics predicts that only the biosimilars that compete with blockbuster and near-blockbuster reference biologics will be profitable.
Contributing Voices
Richard Stefanacci, DO, MBA

It’s hard to believe that one of the most valuable members of today’s interdisciplinary team is still not yet considered a provider for purposes of payment by CMS.

“Pharmacists are remarkably underutilized in the U.S. health care delivery system given their level of education, training, and access to the community,” said a 2011 report from the chief pharmacist office of the U.S. Public Health Service.

The pharmacist’s value has been demonstrated through such programs as the Asheville Project, in which pharmacists in the North Carolina city were encouraged and aided in developing patient services in their stores. The Asheville project has shown, for example, the clinical and economic benefits of a pharmacy-based diabetes care program. The HbA1c levels for patients in the program improved, while direct medical costs for their employer, the city of Ashville, declined.

PBMs: New Power and Influence
Thomas Reinke

David Lassen

Over the past 18 months, formulary exclusion has gone from being a targeted tactic to a commonly used PBM weapon. The drugs kept out are often nonpreferred agents with low utilization, but for the first time a couple of specialty drugs are also on the outs.
Contributing Voices
Peter Wehrwein

No one is against all the progress being made in cancer treatment, which includes milder, effective treatments and medications tailored to take advantage of the genetic weaknesses of tumor cells.

This morning I woke up to front-page story in the Philadelphia Inquirer about the University of Pennsylvania and Novartis settling a patent dispute that had cast a legal cloud over their immunotherapeutic treatments, which rev up a person’s own immune system to take on the cancer and its runaway growth instead of relying on toxic chemicals.

But is the price of this progress just way too steep?

Oncology drugs are a hot topic

Many people are wrestling with these questions. Two sessions this afternoon at the Academy of Managed Care Pharmacy’s annual meeting in San Diego are devoted to management of oncology drugs.

Meanwhile, this morning Health Affairs unveiled its April issue devoted to cost and quality of cancer care.

I thought one of the most thought-provoking articles in Health Affairs was by Darius Lakdawalla, a professor at University of Southern California, and his colleagues.

They argued that we shouldn’t just be looking at the dollar outlay for cancer drugs:

The more complete approach suggested in the health economics literature offsets the growth in costs with the corresponding gain in patient value that resulted from it.

Sounds good. But what is “patient value?”

Interview by Peter Wehrwein

Steve Miller, MD

In a wide-ranging Q&A, Steve Miller, MD, the CMO at Express Scripts, explains why he took the controversial stand again Gilead’s Sovaldi, and how he plans to further gain a handle on drug prices. For instance, “I’ve been advocating for biosimilars very aggressively over the last eight years.”
Tomorrow's Medicine
Thomas Morrow, MD

Thomas Morrow, MD

Enteromedics’s Maestro Rechargeable System also comes with numerous qualifiers for use, and some legitimate questions about long-term efficacy. Payers should pay attention to the entire set of FDA documents in their coverage decisions for this device. Should insurers set and even higher bar for behavior change and lifestyle modification prior to approving payment?
Plan Watch
Frank Diamond

Susan Beane, MD

Price transparency along with cost sharing limits are two ways health insurers can avoid adverse tiering, and the bad publicity (and possible litigation) that goes with it. Four insurers in Florida were accused of discrimination for putting HIV/AIDS drugs on the top tier.
Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD

Richard G. Stefanacci, DO

With retail health clinics popping up left and right, the delivery of care is leaving the confines of the physician’s office and heading for shopping plazas and storefronts. Now hospital care is also on the move and changing venues.