Covering the full cost of combination therapies to prevent patients from having a second myocardial infarction might initially cost health insurers an additional $550 per patient, but then could wind up saving them an average of $1,731 per event, according to a study published in Health Affairs.

But insurers may be hesitant to offer full coverage due to high beneficiary turnover, which can be 20 percent to 30 percent in some cases.

"One insurer may pay for the drugs, while the other reaps the benefits of averted events," says Niteesh K. Choudhry, MD, coauthor of the study. He is an assistant professor of medicine at Harvard Medical School.

"The cost of providing the therapy to everyone, without any patient cost sharing, would be more than offset by the reductions in expenditures from heart attack, stroke, or death that would be avoided by increasing the use of therapy," Choudhry adds.

To determine the potential benefit of full coverage, Choudhry and colleagues observed post-MI rates of death, reinfarction, nonfatal stroke, readmissions for congestive heart failure (CHF), and medication adherence, and estimates of the treatment effect of combination pharmacotherapy, to calculate the expected number of events that would occur if post-MI patients did not receive any secondary prevention. The researchers then calculated the number of events that would be observed with full coverage.

On average, patients pay 32 percent of medication costs. Under the most optimistic assumptions, providing full coverage could increase medication compliance by as much as 26 percent, from 50 percent to 76 percent. For every 100 post-MI patients, full coverage could lead to 1.1 fewer deaths, 13.1 fewer nonfatal heart attacks, and 6.6 fewer readmissions for CHF. Even using conservative assumptions, providing full coverage would increase compliance from 50 percent to 63 percent and result in 0.4 fewer deaths, 5.7 fewer nonfatal heart attacks, and 0.5 fewer nonfatal strokes.

Although this study targeted hypertensive patients, a similar benefit has been demonstrated for other conditions, including diabetes and hyperlipidemia, Choudhry says.

Those conditions, like MI, have treatments that are highly effective, relatively inexpensive, and greatly underused.

"For conditions like acute MI, the benefit from enhanced drug coverage is probably seen within the first year and thus the situation may be different for this condition than for preventive health services that take longer to demonstrate a benefit."

Over a three-year period, the researchers estimate, providing post-MI patients with full coverage would save more than $5,600 per patient.

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.