At what price will a member decide to forgo initiating a specialty pharmaceutical because the out-of-pocket (OOP) cost will cause financial hardship? Prime Therapeutics wanted to find out if there was an association between OOP expenses and abandonment of new prescriptions for tumor necrosis factor (TNF) blockers and multiple sclerosis (MS) specialty drugs.

Patrick P. Gleason, PharmD, director of clinical outcomes at Prime Therapeutics and lead author of the study, says that for members prescribed a TNF blocker, the odds of abandonment (the prescription has been filled, the claim adjudicated and the medication is ready to be dispensed, but the member does not receive or refuses the medication, probably because of the cost) were 6-times higher at an OOP cost greater than $500, compared with OOP costs of less than $100.

Gleason says that “for members filling [a prescription for] an MS medication, if the OOP was more than $200, 1 in 4 were found to have abandoned the drug. If the OOP was less than $100, only 1 in 20 would abandon the drug.”

The researchers studied 6,123 members of a managed care organization who were receiving newly initiated TNF blocker therapy. Nearly 84 percent had a per-claim OOP expense of $0–$100. There were 2,303 members who were newly initiating MS self-injection therapy, 83 percent of whom had a per-claim OOP expense of $0–100.

“Our research suggests that about $200 is the point at which members start thinking of not accepting or not paying for their medication,” says Gleason.

The researchers say that these results “establish potential break points, at which OOP expenses may negatively influence medication utilization, of greater than $100 for TNF blockers and greater than $200 for MS medications.”

Rate of abandonment by out-of-pocket member expense*

The data points for each graph represent 95% confidence error intervals. Because the population within each cost share group is small (with the exception of the $0 to $100 group), the confidence intervals are large. Mathematically, the data point could lie anywhere along the interval.

Out-of-pocket member expense

Source: Gleason PP, Starner CI, Gunderson BW, Schafer JA, Sarran HS. Association of prescription abandonment with cost share for high-cost pharmacy medications. J Manag Care Pharm. 2009;15(8):648–658

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.