There has been a gradual decline in employer-sponsored retiree health benefits for much of the last decade; notably, fewer retirees are offered coverage for prescription drugs. A new analysis suggests that a prescription drug benefit in Medicare would reduce employer expense for health coverage — which, in turn, could encourage more employers to offer some form of drug coverage and thus reverse this erosion. The analysis found that under either of the two basic coverage proposals — a direct expansion of Medicare to include prescription benefits or optional drug coverage — employers would save money, regardless of whether they continue to pay for drug coverage, supplement the core Medicare benefit, or drop coverage altogether.

Projected employer savings under a direct expansion of Medicare
Employers who... Estimated savings*
...retain current level of drug coverage by paying all pharmacy expenses, then take government subsidy for providing coverage 8%
...retain coverage by coordinating benefits (pay supplemental benefits not already covered by Medicare), and pay retiree's Medicare pharmacy (Part D) premium 10%
...retain coverage by coordinating benefits, but require retiree to pay Part D premium 23%
...drop coverage, but pay Part D premiums 67%
...wash hands of all pharmacy responsibility 79%
*Savings per retiree in 2003, when most coverage proposals would begin
Projected employer savings under optional Medicare drug benefit
Employers who... Estimated savings*
...retain current level of drug coverage by requiring retiree enrollment in optional Medicare pharmacy plan and coordinating benefits (pay supplemental benefits not already covered by Medicare), plus pay retiree's premium for optional pharmacy plan 5%
... retain coverage by requiring retiree enrollment in optional Medicare pharmacy plan and coordinating benefits, but making retiree pay premium for Medicare drug plan 29%
... drop coverage, but pay retirees' premiums for optional pharmacy plan 55%
... wash hands of all pharmacy responsibility 79%
*Savings per retiree in 2003, when most coverage proposals would begin

SOURCE: IMPLICATIONS OF MEDICARE PRESCRIPTION DRUG PROPOSALS FOR EMPLOYERS AND RETIREES, A HEWITT ASSOCIATES ANALYSIS FOR THE KAISER FAMILY FOUNDATION, JULY 2000

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.