PPOs are increasingly looking to managed pharmacy programs to help manage drug utilization costs of members with chronic conditions who are taking numerous medications. In general, the larger the PPO (number of members), the more likely it is to use a managed pharmacy program. The Sanofi-Aventis Managed Care Digest Series — HMO-PPO Digest 2010–2011 suggests that in 2009, more than 80 percent of PPOs with 500,000 to 999,999 members had a managed pharmacy program, compared with about a quarter of plans that had fewer than 20,000 members.

By far, the most prevalent managed pharmacy programs involve pharmacy benefit managers. PBMs are playing a greater role as they are involved in administration, dispensing, utilization review, and claims and mail-service processing, according to the report.

With their specialized services in tracking electronic prescribing and medical records, PBMs should be experiencing heightened demand — especially with recent health reform emphasizing the importance of health information technology. For example, PPOs are using PBMs to dispense medications, with 82 percent using PBMs for this service in 2009, up from 78 percent in 2008.

Utilization review had a slight downturn in 2009, says the report, after having a sharp rise from 63 percent in 2006 to 76 percent in 2008. In 2009, almost three-quarters of PPOs surveyed said they used PBMs to provide drug utilization reviews. But the report says PPO reliance on PBMs for drug utilization review is likely to increase, “especially as pay-for-performance and outcomes measures become more prominent in the post-reform era.”

Various services provided by PBMs to PPOs

Source: Sanofi-Aventis Managed Care Digest Series — HMO–PPO Digest 2010–2011

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.