Thirty of thirty-eight Blue Cross Blue Shield health plans surveyed by the Blue Cross Blue Shield Association use a core set of four traditional pharmacy management strategies for outpatient specialty pharmacy: prior authorization, formulary management, utilization review, and claim review for appropriate dosage. Prior authorization — the most common strategy — was implemented by 83.3 percent of respondents, followed by claim review (82.8 percent), formulary management (76.7 percent), and utilization review (70 percent).

The health plans reported that they were more likely to carry out these strategies in-house than to use a vendor. The survey appeared in a recent issue of Health Affairs.

Plans reported that before 2003 they used more in-house programs than outside vendors to manage these costs. In 2003, the number of programs used by the health plans to manage these costs began to rise. The plans in the survey reported implementing 17 new vendor contracts in 2003, an increase from only two in 2002. Eighteen in-house programs were implemented in 2003, an increase from 10 the previous year.

Some plans also reported working with providers and patients to manage the use of specialty pharmaceuticals.

Strategies geared toward providers included providing educational materials and offering incentives to encourage use of specific places of service (home vs. hospital vs. physician's office).

The majority of plans also communicated with their members about specialty pharmacy. This involved providing members with information about service location, methods of obtaining drug products, and information to help members understand benefit design and the importance of taking their medication.

Management of specialty pharmaceuticals, 2003–2005

Source: Blue Cross and Blue Shield Association Outpatient Specialty Pharmaceutical Strategy Survey, 2005

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.