Three tiers or four tiers are the drug benefit designs of choice among employers looking to rein in costs, according to findings presented in the Pharmacy Benefit Management Institute’s Pharmacy Benefit Cost and Plan Design Report. From 2007 to 2008, the percentage of employers who implemented a three-tier plan design with copayments rose from 45.3 percent to 60.5 percent. Overall, more than 75 percent of employers use plan designs with two or more tiers.

Health plans can use the report “to see what types of drug benefit programs employers are implementing in terms of cost sharing and utilization management,” says Dana H. Felthouse, MBA, PBMI president. “They can use the information in their product development. They can also look at utilization, average costs, and average rebates to see how their customers compare to national averages,”

These designs have allowed employers to keep their rate of drug cost increases “to an average of 4.86 percent, the lowest rate since 1995,” says Felthouse. “This is a decline of 2 percent from last year’s survey.”

The survey also shows increases in both retail and mail copayments for generic drugs, preferred brands, and nonpreferred brands.

Source: Pharmacy Benefit Management Institute. Prescription Drug Benefit Cost and Plan Design Report. 2008–2009 edition.

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.