The expense associated with drug misuse is getting a close look from health plans, which are fighting cost battles on two fronts: a double-digit rise in pharmacy expenses and an upturn in medical costs, which have accelerated as utilization reductions have become difficult to sustain. Plans are leaning more on consultant pharmacy and technology for help.

Mississippi received HCFA approval to pay pharmacists for services to Medicaid recipients. Pharmacists will provide education, monitor compliance and manage prescriptions for diabetes and asthma patients.

Pharmacists will be paid $20 a visit. Mississippi is the first state HCFA has approved for such reimbursement, and several other states — fretting about the excessive cost of hospitalization resulting from inappropriate drug therapy — are interested. In Mississippi, that expense approaches about $80 million per year.

John Skhal, Pharm. D., president and CEO of Pharmaceutical Care Network, a Sacramento, Calif.-based pharmacy benefit management company, puts the problem in perspective. "Eighty-five percent of non-trauma-related hospitalizations are due to inappropriate drug therapy," he says.

PCN recently introduced MedIntelligence, a line of software that helps case managers identify medication issues that could result in hospitalization or other unnecessary utilization. Skhal says the program has saved HMOs and independent practice associations $450 per drug-therapy change, not including hospital and physician costs that were avoided.

Similarly, researchers for Merck-Medco, the PBM, reported in the Journal of the American Medical Association Oct. 14 that electronic monitoring can reduce the risk of dangerous drug interactions. In a one-year study of 23,000 people age 65 and up, a computer program flagged 43,000 prescriptions for potential drug interactions and sent warnings to pharmacists. About 6,000 prescriptions were changed.

Managed Care’s Top Ten Articles of 2016

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.