Results of the implementation of a step therapy edit that required HMO members to use a generic antidepressant, excluding tricyclic antidepressants, before using a brand-name antidepressant resulted in drug cost savings of 11.7 percent for the entire class of antidepressants. That worked out to 36 cents per member per month.

The step therapy edit applied only to members with no claim history of antidepressant treatment for the preceding six months. These members were required to use a generic antidepressant. The $5–$10 copayment was waived for the first prescription. Preferred brand-name antidepressants were in tier 2, with a copayment of $20–$25 or coinsurance of 25 percent. Nonformulary brand antidepressants were in tier 3 of the formulary, with a copayment of $40–$45 or coinsurance of 50 percent. Findings were published in the Journal of Managed Care Pharmacy.

The researchers found that the dispensing rate for generic antidepressants increased by 20 percentage points (32.5 percent to 52.5 percent) in the intervention group, but only 7.4 percentage points (24.9 percent to 32.3 percent) in the comparison group (beneficiaries who were not subject to interventions involving antidepressant drug therapy in either 2004 or 2005). Antidepressant drug cost per day of therapy in the intervention group decreased by 11.7 percent in 2005, compared with the previous year. The control group saw a 2.7 percentage point decrease.

"Many MCOs have followed our lead in implementing generic step edits," says Jeffrey D. Dunn, PharmD, MBA, formulary and contract manager at SelectHealth Plans (formerly IHC Health Plans) and lead author. He says the study only focuses on pharmacy costs, and further research is necessary to report about the associated medical costs.

Primary outcomes for the intervention group versus comparison group for antidepressants

Source: J Manag Care Pharm 2006;12(4):294–302

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.