Moving esomeprazole (Nexium) to the third tier of the Tricare formulary and subsequently raising its copayment from $9 to $22 for a 30-day supply resulted in a 25-percent reduction in the number of prescriptions filled in the month after the change, according to research published in the January/February issue of the Journal of Managed Care Pharmacy.

Over the 24-month study period, the total numbers of proton-pump inhibitor fills and of PPI users increased by 8.5 percent and 9 percent, respectively, but the number of esomeprazole users decreased 4.6 percent.

Researchers observed a statistically significant growth in esomeprazole fills during the six months before the switch and a significant reduction in the month immediately after the formulary change.

Of the 117,801 esomeprazole users, 73.3 percent continued using esomeprazole, 15 percent switched to other prescription PPIs, 0.6 percent used only non-PPI prescription therapy, and 11.1 percent discontinued all prescription acid-reducing therapy.

Although the formulary change apparently resulted in a reduction in esomeprazole use, the magnitude of the change was relatively modest. The authors suggest that the unprecedented spending by the drug’s manufacturer on direct-to-consumer advertising may explain, in part, the consumer’s willingness to spend more on esomeprazole when several less costly therapeutic equivalents were widely available. The authors also suggest that even the $22 copayment was still substantially less than what most health plans charge for third-tier medications, and many Tricare beneficiaries may not be price-sensitive until an out-of-pocket threshold cost is reached. More dramatic formulary changes such as step therapy may be required to promote greater use of first- and second-tier medications.

Source: Linton A, Bacon T, Peterson M. Proton-pump inhibitor utilization with the change to nonpreferred formulary status for esomeprazole in the TRICARE pharmacy. J Man Care Pharm 2009;15(1):42–54

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.