Discounts in average wholesale price for brand-name drugs in retail pharmacy increased from 14.5 percent in 2003 to 14.8 percent in 2004. Overall, the AWP discount increased by 3 percentage points from 1995 to 2004, according to the Prescription Drug Benefit Cost and Plan Design Survey Report, 2005 edition, from the Pharmacy Benefit Management Institute. The report is based on data collected from 404 employers with approximately 8.6 million beneficiaries.

The average retail dispensing fee for branded drugs decreased from $2.05 in 2003 to $1.95 in 2004.

The average reimbursement rate, a combination of AWP and average dispensing fee, declined from 87.7 percent in 2003 to 87 percent in 2004.

Mail-service discounts also increased. The average discount from AWP for branded drugs delivered by mail-increased by 0.6 points from 20.4 percent in 2003 to 21 percent in 2004. Average mail dispensing fees decreased from $0.52 in 2003 to $0.41 in 2004. The average reimbursement rate, which is a combination of AWP and average dispensing fee, declined from 79.7 percent in 2003 to 79.1 percent in 2004.

In 2000, 58 percent of employers paid retail pharmacies 87 percent or higher of the AWP for brand drugs. In 2004, only 10 percent of employers reported paying that amount. Also in 2000, 6 percent of the survey respondents reported paying less than 85 percent of the AWP. By 2004, 30 percent of employers reported paying less than 85 percent of the AWP.

More discounts, lower fees for retail pharmacies

Trends in mail service reimbursement

Source: Prescription Drug Benefit Cost and Plan Design Survey Report, Pharmacy Benefit Management Institute

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.