Safer care

Re: “Improving Care — 3 Success Stories,” March 2011.

These examples demonstrate that focusing on care improvement as a primary goal can lead to both safer care and meaningful savings.

This is important to health plans for two key reasons: It shows how plans can accomplish the triple aim of health care reform as voiced by Donald Berwick, MD (“better care, better quality, lower cost”), and it also provides a basis for how plans and accountable care organizations will be able to align their goals to benefit stakeholders.

Derek VanAmerongen, MD
Cincinnati, Ohio

No rapid antidote

Re: “Next Generation Anticoagulants,” February 2011.

Coumadin is, of course, cheaper, and with the home self-testing INR devices, we have seen an improvement in compliance. My main concern is that there is no rapid antidote to these new drugs in cases of emergency, as there is with Coumadin and heparin.

Analysis takes time and often the circumstances cannot wait. The cost will be a definite drawback for the utilization of these newer agents.

Kenneth Allen, MD
Saint Clairsville, Ohio

Arbitrary, unfair

Re: “MCO Works Hard to Integrate Specialty Pharma Operations,” February 2011.

The lack of consistency in formulary designs that use preferred and nonpreferred agents is perceived as arbitrary and unfair by patients and their advocates.

The National Multiple Sclerosis Society finds that it is not unusual for one health plan within a state to designate two MS drugs as preferred while at the same time another health plan within the same state gives the same two MS drugs the exact opposite designation. To this confusion can be added changes within the same formulary.

It is distressing to read letters from health plans to their enrollees telling them that the drug they have been taking for years is now being re-classified as “nonpreferred” and they now need to pay significantly more out of pocket if they want to remain on that drug.

Patients are being put into the position of paying more, or switching drugs, with no clinical reason provided. Until there is strong head-to-head evidence-based data comparing the MS drugs, such decisions are perceived as totally random and unrelated to individual patient response.

Kimberly Calder
Federal Health Affairs and Insurance Policy
National MS Society
Washington, D.C.

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.