When it comes to making decisions about including a medication on a drug list, Lisa A. Bero, PhD, a professor of clinical pharmacy and health at the University of California–San Francisco, says that “selection for any list — a formulary, an essential-medicines list, a preferred drug list, or a reimbursement list — should be made based on the most rigorous evidence of safety and efficacy.”

She and her colleagues compared state Medicaid preferred drug lists (PDLs) with the World Health Organization’s Essential Medicines List (EML), and found that only 6 of 120 agents on the EML appeared on fewer than 50 percent of PDLs — meaning that most PDLs listed the essential medicines.

However, many medicines appeared only on PDLs and not the EML. These medicines were less likely than EML agents to have generic versions available (56 percent vs. 76 percent) and less likely to be first-line treatments (21 percent vs. 41 percent).

The researchers noted a weak association between presence on the guidelines of the National Institute for Health and Clinical Excellence (NICE), which are developed using evidence-based methods, and PDL listing. This may indicate that clinical effectiveness is not a primary motivator for state PDL decisions. The researchers used the NICE guidelines because the United States does not publish national, standardized, evidence-based treatment guidelines.

Bero says that most PDLs “did seem to have the core medicines that corresponded with the EML, but outside of that, the variability became great. So there were a lot of nongeneric products. There were a lot of products that serve the same purpose in terms of treatment efficacy. That raises the question about the evidence base for putting those medicines on the list.” And that makes checking drug lists multiple times all the more important.

These agents appear on only 1 preferred drug list
Eight medications were listed on only 1 PDL. None of these medicines was available as a generic formulation or recommended as a first-line treatment. “Why are these products on some PDLs instead of the more affordable, recommended products?” asks Lisa A. Bero, PhD. “They may be on the PDL because they are part of a ‘package deal’ of medicines. So they may be there for economic, not public health reasons.”
Agent Therapeutic class State
Zileuton CR Antiasthmatic Pennsylvania
Arformoterol Antiasthmatic Utah
Eprosartan Antihypertensive South Carolina
Eprosartan + HCTZ* Antihypertensive South Carolina
Saxagliptin Antidiabetic Montana
Aliskiren + valsartan Antihypertensive District of Columbia
Paliperidone Antipsychotic Washington
Tapentadol Analgesic Alabama
*HCTZ = hydrochlorothiazide

Source: Millar TP, Wong S, Odiema DH, Bero LA. Applying the essential medicines concept to U.S. preferred drug lists. Am J Public Health. 2011;101:1444–1448

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.