With the exception of specialty drugs, enrollees in Medicare Part D plans paid more for their commonly used drugs than beneficiaries in employer plans, according to a recent report, “Medicare Prescription Drug Plans in 2008 and Key Changes Since 2006: Summary of Findings.” Although there has been minimal change in coverage benefits among Part D formularies since 2006, there has been an increase in cost sharing and utilization management restrictions, which can have important implications on beneficiaries’ access to medications or out-of-pocket expenses.

Medicare Part D plans (PDPs) charged more in 2007, on average, for preferred and nonpreferred brand drugs than did employer plans, and the financial incentives for drug switching (from nonpreferred to preferred drugs and from brands to generics) appear to be stronger in PDPs than in employer plans, according to the analysis.

Since plans have very different levels of enrollment and different cost sharing, “describing the cost sharing of a typical beneficiary may be difficult,” says Elizabeth Hargrave, senior research scientist at the National Opinion Research Center (NORC) at the University of Chicago. She is a coauthor. The researchers gave “more weight to the more common plans and less weight to some of the more obscure plans,” Hargrave says.

Change in weighted average cost sharing for national PDPs and for employer-sponsored plans

Note: Based on plans with three flat-dollar copayment tiers and includes only plans that will be offered in 2008.

Source: Georgetown University/NORC analysis of data from CMS for the Kaiser Family Foundation; employer plan data from Kaiser/HRET employer health benefits survey

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.