In a recent study, it was shown that step therapy may create barriers for members to receive medication, and ultimately result in higher medical utilization and costs.

That study, published in the American Journal of Managed Care, reports that employers who had implemented step therapy for angiotensin-converting enzyme inhibitors/angiotensin receptor blocker medications were compared with employers who had not implemented step therapy.

Tami L. Mark, PhD, MBA, director of analytic strategies at Thomson Reuters Health Care and lead author, says that “step therapy is becoming very common and there’s a need to evaluate what its impact is, and not assume what its impact might be.”

This study focused on all types of medical care utilization and spending — prior research has shown that drug costs decrease when a step therapy program was implemented.

The researchers reported an initial 7.9 percent reduction in days of medication supplied and an initial 3.1 percent reduction in costs for employers that used step therapy.

“We did find that patients discontinued their medication more so after step therapy was implemented,” says Mark. “There was a decrease in prescription drug costs in the step therapy group relative to the control group, although that effect diminished over time. Conversely, we found that emergency room visits and hospitalizations increased and that total medical care costs increased.”

Quarterly expenditures in the step therapy group were $99 more per user than in the comparison group after eight quarters.

Effects of step therapy on expenditures

Difference between step therapy plans and comparison plans in each quarter after start of step therapy

Source: Mark TL, Gibson TB, McGuigan KA. The effects of antihypertensive step-therapy protocols on pharmaceutical and medical utilization and expenditures. Am J Manag Care. 2009;15(2):123–131

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.

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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.

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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.