Medicaid, enacted in 1965, is currently costing over $200 billion per year. With rapidly rising health care costs, including prescription drugs, state Medicaid budgets are feeling the strain. Like its effect on private insurance, prescription drug costs had the highest growth rate among Medicaid services, increasing approximately 19 percent over the past several years. To combat this trend, states are employing several strategies.

In particular, more states are concentrating efforts to control costs through preferred drug lists (PDLs). As of last September, 39 states had some type of control restricting access to certain prescription drugs. These controls have taken the form of PDLs, prior authorization processes, or prescription limits. Last year alone, 49 states had filed a total of 290 legislative bills concerning their pharmaceutical programs or policies. This year, there will be even more activity and uncertainty at the state level regarding drug costs.

"Despite all of this legislative activity, there is no guarantee that the states will see any savings," says Brian Bamberger, president of MediMedia Information Technologies. "In fact, there is a growing body of evidence that says the opposite is true. Several studies have been published concluding that the more restrictions are introduced by states, the more patients move to higher-priced Medicaid services." In addition, due to federal statutes, states have limited authority to adopt formularies.

MediMedia Information Technologies has launched State Medicaid Monitor, a database service that includes copayment ranges, enrollment statistics, demographic statistics, prior authorization procedures, and excluded drug classes. The information in the monitor can be used to compare specific restrictions or policies regarding a specific therapy to any other state in the data source.

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.