A second multistate drug-purchasing effort is forming, this time in the Southeast. Led by West Virginia Gov. Bob Wise, the group-buying effort includes Alabama, Georgia, and the Carolinas. Washington State is also participating in the talks, which have thus far consisted of two meetings, most recently on April 30.

The states are interested in pooling their buying power to try to force greater rebates from drug manufacturers. The effort is similar to a drug-buying pool launched by Maine, New Hampshire, and Vermont last year. The New England effort is aimed at reducing the cost of pharmaceuticals for Medicaid recipients, state employees, and the uninsured — about 1.3 million people. In late April, Wise signed legislation that would create a purchasing pool for state workers; one strategy under consideration is directing business to a single pharmacy benefit manager.

In another pharmacy-related development, WellPoint Health Networks presented evidence to the FDA May 11 on its request to switch popular branded antihistamines to over-the-counter status. WellPoint says they are safer than current over-the-counter products; pharmaceutical companies say it's all about shifting costs to the consumer. It's the first time someone other than a manufacturer has requested OTC status for specific prescription products.

Those products, and many others, are heavily promoted to the public. Now, the FDA has begun a review of its 1997 policy that allowed direct-to-consumer advertising to explode — to the chagrin of MCOs, which claim the FDA unleashed a trend that sent their pharmacy costs skyrocketing. The FDA will decide by year's end whether the ads "confuse consumers and adversely impact the relationship between patients and their health care providers."

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.