Managed Care


Contributing Voices
Saeed Aminzadeh

As the country’s population of non-native English speakers continues to grow, language differences have become a significant barrier to engaging health plan members and keeping them as healthy as possible.

Last fall, the Census Bureau released data showing that one out of every five U.S. residents doesn't speak English at home.

In fact, the number of people who speak a language other than English at home has reached an all-time high of 61.8 million, up 2.2 million since 2010. The largest increases from 2010 to 2013 were speakers of Spanish, Chinese, and Arabic.

Health plans most  work closely with their members who are non-English speakers.  Population health analytics tell us that language barriers affect care and membership loyalty:

Contributing Voices
Ted Slafsky

Contrary to the highly misleading picture painted by critics, the 340B drug discount program is working as Congress intended and helping millions of underserved Americans receive better healthcare every year.

The pharmaceutical industry has gone to great lengths to misconstrue how the program functions in an effort to vilify safety-net hospitals. These are the urban and rural facilities across the country that care for all patients, regardless of their ability to pay.

Contributing Voices
Frank Diamond

Maybe it’s because cars are fun and we’re young when we start driving that we slide easily into the habit of paying automobile insurance. Or maybe it’s because cars are dangerous and our parents and/or the state wouldn’t let us drive without it. The metaphor of allowing beneficiaries to buy health insurance as they do car insurance (just this side of hoary when we used it back in 1998: left reality in the dust ages ago. It sounds so nice, but it’s still not happening, according to a Kaiser Family Tracking Poll released in April 2015 (

This, despite all the talk of transparency and the overabundance of evidence that two providers can charge very different prices for the same procedure in the same town and get the same outcomes. This, despite the continuing shift in costs to beneficiaries. In the poll, 2 out of 3 people say that finding out how much doctors or hospitals charge is too difficult. Only 6% of people use quality rankings to make a decision about an insurer, doctor, or hospital.

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.”

Contributing Voices
Peter Wehrwein

If the jury is still out on ACOs, a study by Harvard researchers published in today’s New England Journal of Medicine could be a sign that the verdict will ultimately be that they work.

Judging by these results, ACOs seem effective at reducing health spending, albeit by a modest amount, but may not make much of a difference when it comes to performance measures like hospital readmission.

CMS has previously reported that Pioneer ACOs are a spending reduction success story and save the Medicare program money.

What’s new here is that an independent group of researchers, using some rigorous research methods, have arrived at pretty much the same conclusion.

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.

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.

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?”

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