John Marcille

John Marcille

You get what you pay for. ” Too often, that’s a justification for high prices. Yes, the Jaguar is a nice car, but with the quality-control problems that it had until recently, were you really getting what you paid for?

Employers are growing increasingly savvy about what they get for their money, and so are insurers. Linda Cahn’s article on how to negotiate with PBMs over coverage of specialty pharmaceuticals is a good example, as it can apply to insurers as well as employers. And the piece by F. Randy Vogenberg, RPh, PhD, describes another approach to getting more value from the biotech budget.

Lola Butcher tells us how payers are succeeding in wringing more value from their imaging budgets, with some cooperation from providers.

You may want to start with Martin Sipkoff’s cover story. He discusses the very concept of value in health care and gives a very simple-to-grasp formula from Denis Cortese, MD, head of the Mayo Clinic. Then he goes on to describe development in value-based insurance design, which is drawing greater interest from employers, health plans, and the federal government, since it holds the promise of using price to encourage quality. Don’t charge everyone the same price for a drug or procedure; set the price for the individual patient based on whether the therapy will make a big difference in his condition. Most effective therapies get the lowest prices.

This of course is one of those scenarios where you’d like to avoid churning. If you are reducing cost-sharing to encourage use of a particular therapy, you want that patient to be around for the payoff — fewer visits to the emergency department, for example. Real attention to quality, which the federal government is also promoting in its comparative effectiveness program, seems to be a good idea for anyone paying the bills.

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.