John Marcille

I’ d love to tell you that we planned it this way, but it just happened. Many of the articles this issue deal with managing pharmaceuticals, with several focusing on specialty pharmacy. I pull a comparison from the shelf, one about publishing a newspaper before a presidential election: One topic overrides all others. There’s this difference, though: Elections end, but the challenges of medication use (and non-use) will always be with us. I think pharmacy might be more complex than politics, but that people in both fields share some of the same motives.

Our cover story came about because I found this interesting fact in the Express Scripts “2011 Drug Trend Report”: 37 percent of cancer patients on oral chemotherapies do not adhere. That shocked me. Nearly 40 percent of patients fighting an often life-threatening disease don’t take their medication? Managing Editor Frank Diamond’s report explains why, how such nonadherence leads to more costs down the road, and what one leading insurer has been doing about it.

Our supporting cast includes (in no particular order) stories about prior authorization for clinical, not cost, reasons, how providers at Memorial Sloan-Kettering said no to Zaltrap, how employers want a bigger role in managing specialty pharmacy, some new drug management techniques in general, tumor treating fields therapy, and how Geisinger Health Plan is handling the nonadherence problem for chronic disease.

Even the articles that don’t deal directly with drug management — such as the one about the Patient-Centered Outcomes Research Institute and the one about mental health parity and the old “carve in or carve out” choice — in their way touch on drug therapy.

Where does that leave us? With more threads to follow in the complex web of managed health care.

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.