Growth in health care spending has actually slowed in the last few years, according to a study by CVS/Caremark. In fact, in 2010 it grew more slowly than it had in over 50 years. “Analysts attribute this slow growth to the recession — people continue to tighten their belts and focus on ‘necessities’ even as the economy slowly recovers,” says the study, “Insights 2012.” Money concerns might be causing people to not get care. “While the number of people with insurance has declined over the last few years, even the insured are going to the doctor less frequently.”

Costs are expected to surge in 2014. For one thing, eventually people will have to get needed care. For another: “While the future of the ACA’s individual mandate is uncertain, many provisions of the [Affordable Care Act] have already been enacted and embraced. These parts of the act would probably be difficult to reverse.”

The authors expect that utilization will remain flat through this year, but will pick up in 2013. “Specialty pharmaceuticals will continue to be the primary driver of prescription [cost increases] for the next several years,” the study states.

Meanwhile, “the specialty market is growing and is likely to become a larger share of every payer’s budget during each coming year. Management techniques of yesterday and today will need to be improved … to manage the … challenges posed by the uniqueness of the specialty market.”

In 2010, three specialty drugs were among the top-10 selling drugs. In 2016, specialty drugs are expected to be 7 of the top 10.

Highest-cost drug mix to change

orange = specialty

2010 TOP TEN
Drug Revenue Indication
Plavix $6.1B Cardiac/stroke
Lipitor $5.1B High cholesterol
Advair $4.1B Asthma, chronic obstructive pulmonary disease
Remicade $3.57B Rheumatoid arthritis
Seroquel $3.56B Schizophrenia, bi-polar
Abilify $3.4B Bi-polar, depression
Actos $3.3B Diabetes
Enbrel $3.2B Autoimmune disorders
Avastin $3.25B Oncology
Singulair $3.21B Asthma
2016 TOP TEN
Drug Revenue Indication
Rituxan $3.57B Oncology
Humira $3.54B Rheumatoid arthritis
Avastin $3.45B Oncology
Januvia/Janumet $3.42B Diabetes
Advair $3.27B Asthma, chronic obstructive pulmonary disease
Revlimid $2.95B Oncology
Lantus $2.80B Diabetes
Enbrel $2.78B Autoimmune disorders
Remicade $2.62B Rheumatoid arthritis
Atripla $2.56B HIV

Expenditure for 10 largest drug categories 2010–2016

All amounts in billions

Source: “Insights 2012: Advancing the Science of Pharmacy Care,” CVS/Caremark

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.