A recent report from the IMS Institute for Healthcare Informatics suggests a continuing shift toward government payers (Medicare and Medicaid) to help beneficiaries pay for prescription medications.

Commercial insurance was used to pay for 63 percent of dispensed prescriptions in 2010, according to the report, The Use of Medicines in the United States: Review of 2010. That is down from 66 percent five years ago. Thirty percent of all prescriptions in 2010 were filled under a Part D plan or through Medicaid. That number was 22 percent in 2006 — a clear indication of greater dependence on government programs for medications. Part D was launched in 2006.

The report attributes the changes to the slow growth of the economy in 2010 and high unemployment.

The institute found that Part D beneficiaries filled 871 million prescriptions in 2010, up 6.4 percent and accounting for nearly 22 percent of all prescriptions. Medicaid prescriptions increased by 13.7 percent, to 336 million, in 2010.

Cash payments declined by 10.3 percent, to 273 million prescriptions. Private insurance accounted for 62.9 percent of prescriptions in 2010, versus 64.1 percent in 2009.

The report says total spending on medications was $307.4 billion in 2010, up from $300.3 billion in 2009. There was an $8.3 billion decline in the volume of branded product spending in 2010 compared to 2009. Brands losing patent protection or exclusivity in 2010 resulted in a reduction in spending of $12.6 billion.

Dispensed prescriptions by payment type

Source: IMS Institute for Healthcare Informatics. The Use of Medicines in the United States: Review of 2010.

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.