John A. Marcille

John A. Marcille

In case you hadn't noticed, employers and insurers are engaged in a headlong process of transferring health care costs to the insured employees. The term "price sensitivity" also is used a lot, the idea being that you might not push for that medically-optional, expensive drug, procedure or test. But while there's logic and evidence that price sensitivity can lower immediate costs to employers, we need information about other effects of shifting costs directly to consumers (who, of course, pay those costs already, albeit indirectly, in the form of lower wages, economists tell us).

So when I read this interesting study in JAMA (May 19, 2004,) by Dana P. Goldman, PhD, et al, of Rand, I wasn't too surprised. I will, of course, oversimplify: Raise copayments for drugs and some people will get fewer doses than they need — really need.

"When we examined the chronically ill population receiving routine care, a group of patients who are most likely to benefit from drug treatment, we still found that doubling copayments is associated with reductions in drug use of 8% to 23%," the authors write. We're talking dyslipidemia and diabetes, especially, and you know what noncompliance can mean for those patients.

Happily, these patients showed less of a drop in annual days supplied than did patients who used prescription antihistamines and NSAIDs. Perhaps people are smarter than I had suspected, though the success of "reality" TV makes me wonder.

We need to pay attention to the health effects of benefit changes and avoid jumping on the cost-shifting bandwagon until we know more. Or do you physicians and pharmacists who constitute the great majority of my readers disagree?

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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.