Long-term research needs to be done on the cost effectiveness of biologics in fighting rheumatoid arthritis before health plans can be convinced that coverage of the new agents will save money in the long run, a recent study suggests.

"Taking into consideration the high costs of biologic agents and relatively high rates of use, health care plans may begin to demand evidence of cost effectiveness," says "Impact of Managed Care on the Use of Biologic Agents for Rheumatoid Arthritis" in the June 15, 2005 issue of Arthritis & Rheumatism. "To establish the cost effectiveness of treatments for RA, it is imperative to show a reduction in rates of joint replacement surgery and work loss, because the former may account for as much as 25 percent of direct costs . . . and the latter may account for as much as 70 percent of total costs of this illness. Because rates of joint replacement are relatively low in any one year and work loss unfolds over a decade or more, it will be difficult to establish that the biologic agents are cost effective without long-term trials of these agents."

HMOs were much less likely to cover biologics than were other forms of insurance, such as fee-for-service care, from 1999 to 2002, according to the study. In addition, biologic coverage for patients in HMOs was much more likely to be terminated, according to the data that were collected mainly through telephone surveys. One caveat: It wasn't clear whether the financial incentives in HMOs were the factors that most caused this apparent gap in use of biologics. In addition, the study says that the hesitancy on the part of HMOs may be due to lack of information.

Other factors must also be weighed. "For example, older age, longer disease duration, and a slightly higher number of comorbid conditions of persons with RA in fee-for-service settings may play a role in their higher rates of use of biologic agents," says the study.

There are some implications for the newly launched Medicare Part D program. "Many persons with arthritis are currently choosing Medicare drug plans," Edward H. Yelin, PhD, and the main author of the study, is quoted on the Arthritis Foundation Web site. "As they make the choice among plans, they should be cognizant not only of the drugs they are currently taking but of those that may be prescribed for them in the years to come."

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.