Filling the gap in coverage in which the enrollee pays 100 percent of total drug costs before catastrophic coverage begins — the so-called doughnut hole — will be a significant issue that stand-alone Prescription Drug Plans (PDPs) and Medicare Advantage Prescription Drug (MA-PD) plans face in 2008. In 2008, the coverage gap totals $3,216 for plans offering the standard Medicare Part D benefit. That number is projected to exceed $6,000 by 2016, according to a report from the Henry J. Kaiser Family Foundation.

In response, 29 percent of PDPs (529 plans) will offer some type of gap coverage in 2008, up from 15 percent (220 plans) in 2006. The proportion of MA-PD plans offering some gap coverage has also grown, from 28 percent (369 plans) in 2006 to 51 percent (964 plans) in 2008.

From 2007 to 2008, generic drug coverage by PDPs will remain stable, but in 2008 “we will see some modification to the type of coverage offered,” says Juliette Cubanski, principal policy analyst at the Kaiser Family Foundation. “Plans are starting to segment their tiers for generic drugs, so it’s not just tier one, tier two, and tier three but value generics, preferred generics, and nonpreferred generics,” says Cubanski. About half of the PDPs with gap coverage in 2008 are covering only preferred brands or a subset of generics.

In 2008, there will only be one PDP in one region that is covering some brand-name drugs and generic drugs in the gap. About 300 MA-PD plans will offer limited coverage of brand-name drugs in the gap. Nearly all of the stand-alone PDPs offering gap coverage and more than half of the MA-PD plans offering gap coverage will cover generic drugs exclusively in 2008.

“There’s been a dramatic evacuation of plans from the market,” says Cubanski. “Plans are still offering gap coverage but they are limiting the scope of that coverage so that there are more restrictions on the types of drugs covered. Brand-name drugs are not as commonly covered as they were in previous years.”

*In 2008, one PDP will offer gap coverage for brand-name drugs (rounds to 0 percent).

Source: The Henry J. Kaiser Family Foundation. “Medicare Part D 2008 Data Spotlight: The Coverage Gap,” November 2007.

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.