With 2010 well under way, Medicare beneficiaries participating in Part D plans face increasing drug prices for which they will have to pay 100 percent of total drug costs after their spending exceeds the initial coverage limit, according to a new report from the Kaiser Family Foundation. It should be noted, though, that the new health reform law makes changes to the coverage gap beginning in 2010, with a $250 payment to anyone who reaches the “doughnut hole.”

It is expected that these increases in drug prices will far exceed the growth of inflation. But Juliette Cubanski, principal policy analyst at Kaiser, cautions that the environment is too unpredictable, especially with drug prices.

She says, “If history is any guide, price increases are more likely than not for brand-name drugs — but the extent of that increase is not within the scope of our research.”

Under current law, the coverage gap under the Part D standard benefit is $3,610 in 2010 and is projected to increase to $5,755 by 2018. In 2007, an estimated 3.4 million Part D enrollees reached the coverage gap.

Between 2009 and 2010, monthly prices in the coverage gap increased by 5 percent or more for half of the top ten brand-name drugs that did not have a generic substitute for enrollees in stand-alone prescription drug plans (PDPs) — whereas the Consumer Price Index for urban consumers (CPI-U) increased by 2.7 percent and the CPI for medical care (CPI-M) increased by 3.5 percent.

Prices for top ten brand-name drugs in national PDPs, 2009–2010

Source: Kaiser Family Foundation. Prices for brand-name drugs in the coverage gap. March 2010

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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.