Managed Care
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.
Richard Mark Kirkner
Not so long ago, hospitals, physicians, and insurers all looked with wariness upon retail health care clinics. Now, they are seen as cost-effective allies that could help to relieve the ever-swelling backlog of patients seeking care. Quality? So far they seem to measure up.
Contributing Voices

They are relatively cheap to develop, since clinical trials are small and “the lack of alternative treatments give orphan agents an advantage when up for regulatory review,” according to a report by Evaluate, a life science market intelligence company that provides forecasts on that sector. The company’s second annual EvaluatePharma Orphan Drug Report says that orphan drug sales will make up 19% of prescription drug sales by 2020, totaling about $176 billion.

Insurers will have their hands full because even though the populations that need orphan drugs are small “they represent big per-patient outlays, and insurers will be looking carefully at new tools to arrest cost growth as more and more orphan drugs launch,” says the study. The cost per orphan drug per patient is six times that of non-orphan drugs.

Worldwide Orphan Drug Sales & Share of Prescription Drug Market (2000-20)

Average Cost per Patient per Year 2010-14

Source: “EvaluatePharma Orphan Drug Report 2014,” Evaluate 

News & Commentary
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.
Biologics In Development
Katherine T. Adams
Radiation therapy and androgen deprivation therapy (ADT) resulted in a 57% reduction in death from prostate cancer for men between the ages of 65 and 75, according to a National Cancer Institute study. Men 76 to 85 who received radiation therapy in addition to ADT also lived longer.
Contributing Voices
Peter Wehrwein

We usually want to be in the middle of networks with plenty of strength and sprawl. People strive to have large professional and social networks. Wirelesss carriers brag about how big and reliable their networks are.

It was that way in health care, too. After the pushback against managed care in the 1990s, insurers loosened the reins. Come open enrollment, people were enticed to sign up for a health plan that had cast a wide net with a wide choice of providers or, often more importantly, a plan that their favorite doctor accepted.

But now all talk is of narrow networks and being much more selective—some providers say discriminatory—about which providers are included in health plan’s network, all in the name of value-based care.

Medication Management
Thomas Reinke

Ronna Hauser, PharmD

Preferred pharmacy network plans have taken over in the Medicare Part D program, foreshadowing the possibility of widespread changes in how plan sponsors contract with retail pharmacies. Meanwhile, community pharmacies want CMS to adopt any-willing-provider provisions to let them in.
Susan Worley

Jennifer R. Marin, MD, MSc

Some high-profile cases involving celebrities have Americans paying more attention to traumatic brain injury and going to emergency departments in record numbers as a result. Thoughtfully designed treatment guidelines might help physicians determine the severity of an injury and, eventually, cut down on ED visits.
News & Commentary
Patients diagnosed with cancer often stop taking their medications for diabetes. One possible reason is the “life chaos” that comes with the diagnosis of, and treatment for, cancer. Researchers tracked more than 16,000 patients with diabetes between 1998 and 2011.
Formulary Files
Krishna Rutvij Patel, PharmD
Close to half of pharmaceutical industry executives favor the FDA factoring economics into their approval decisions, something that most of them dreaded not too long ago. A survey by PwC suggests that the move toward value-based payment might have something to do with this.
Medical Device Monitor
Katherine T. Adams
In light of the tremendous implications for overuse, misunderstandings, and abuse of a person’s genetic and disease-risk data, regulators have a lot to think about. Next-generation sequencing will produce such a massive amount of data that a totally new approval procedure would be required.
Cover Story
Timothy Kelley

Dean Sittig, PhD

Watch out for “e-iatrogenesis,” which can be found at the intersection of technology and the human beings who use it — and misuse it. Though HIT improves patient safety, it can also help to create new kinds of errors that can cause some harm. Here’s what insurers can do about it.
News & Commentary
In 2011, 48% of new MA enrollees were new to Medicare and 52% had switched out of the traditional program, according to Kaiser Family Foundation researchers. In past years, a greater percentage came from those who switched from the traditional program.