THE FORMULARY FILES

A recent survey indicates that prices for the top 20 drugs used by Medicare enrollees are much higher than prices negotiated by the Department of Veterans Affairs. According to the report "Falling Short: Medicare Prescription Drug Plans Offer Meager Savings" from Families USA, the median difference for those top 20 drugs is 48.2 percent.

Only drugs that were on a Medicare prescription drug plan's formulary — drugs for which the plan would have actively negotiated prices — were included in the analysis.

The survey ruffled feathers at the Pharmaceutical Care Management Association, whose own survey finds that PBMs are negotiating deep discounts in Medicare. PCMA says it will save Medicare beneficiaries an average of 31 percent at retail pharmacies and 45 percent through mail-service pharmacies, compared to the customary prices that retail pharmacies charge. In itself, this statement does not contradict the Families USA study.

PCMA contends that a VA-style approach to Medicare drug pricing would lead to higher costs for working families, unions, and small businesses and limit Medicare enrollees' access to covered drugs and pharmacies. According to PCMA, the VA drug program is not comparable because it is highly restrictive and provides access to only about 250 pharmacies nationwide, compared to 55,000 pharmacies under Medicare Part D.

To obtain the Families USA study, go to «http://www.familiesusa.org/assets/pdfs/PDP-vs-VA-prices-special-report.pdf». For the PCMA study, go to «http://www.pcmanet.org/newsroom/PCMA%20on%20Families%20USA%20Higher%20Costs%20Fewer %20Choices%20(12-21-05).pdf».

Source: Families USA, Falling Short: Medicare Prescription Drug Plans Offer Meager Savings.PBMs discounts on top drugs used by Medicare enrolleesPDP=Prescription Drug Plan

Source: PCMA, Higher Costs, Fewer Choices: What Families USA's New Report on Medicare Drug Prices Isn't Telling America's Seniors & Disabled.

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.