The debate among state legislators and managed care regulators about coverage of Viagra, Pfizer's popular anti-impotence medication, continued on two fronts last month. A number of states rejected a federal order that

Medicaid programs cover the drug. And legislators in California called for an investigation of commercial health insurers that have decided not to cover Viagra because of cost.

State Medicaid officials in New York, Michigan, Wisconsin and Indiana have said they will not cover the drug — in defiance of the federal directive. Indiana dropped Viagra coverage July 1; the state's rationale is that Viagra should be classified as a fertility drug. Such medications, along with smoking-cessation treatments, penile implants and cosmetic medications, are excluded from Medicaid coverage.

The National Governors' Association criticized the Clinton administration's decision to require Medicaid coverage, calling it an unfunded federal mandate. "The administration is making a substantial, premature, unilateral policy decision without the benefit of consultation with the states," said Jennifer Baxendell, the association's director of health legislation. The association argues that states should have the option to cover Viagra, which the group estimates could cost Medicaid $100 million a year.

In a letter to the association, HCFA Administrator Nancy-Ann DeParle defended the coverage mandate. "The FDA has approved Viagra only to treat erectile dysfunction in men," DeParle wrote. "Viagra does not fall within any of the allowable exclusions or restrictions."

In California, advocates of patients with prostate cancer and spinal cord injuries, as well as legislators, called for a state investigation of Kaiser Permanente and Aetna U.S. Healthcare, both of which decided not to cover Viagra because of costs. Assemblyman Tom Bordonaro Jr. argued that the decisions set "a very dangerous precedent." Health plans are legally required "to provide medically necessary treatments. By conscience, they should provide the least painful, most effective treatments for a condition."

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.