The majority of respondents to a survey that examined comparative effectiveness (CE) research and biologic agents predicted that within the next five years, CE research will be required to support coverage decisions concerning biologic therapies. The results were published in the 2009 Biotechnology Monitor & Survey: Marketplace Policies, Practices, and Perspectives.

In 2008, 17 percent of Medicare Advantage plan pharmacy and medical directors performed therapeutic outcomes studies to assess biologic therapies in their own organizations. Thirty-nine percent plan to conduct CE research in 2009.

Marsha Fahey, managing editor and research director of the survey, says, “It’s a sign that there’s a lot of attention being paid to biologics.” Is it too late for health plans that haven’t started conducting this research? “Health plans haven’t missed the boat,” she says. “A lot more data will be available from CMS soon.”

She notes that oncologists are much more familiar with CE research. “Comparative effectiveness forms protocols and guidelines. The National Comprehensive Cancer Network, an alliance of 21 cancer centers, has been using it for a long time, and most oncologists look at those evidence-based guidelines to make decisions,” says Fahey.

Health plans’ involvement in CE research

Source: 2009 Biotechnology Monitor & Survey: Marketplace Policies, Practices, & Perspectives

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.