Expect wellness efforts to explode in the next few years as companies, federal and local governments, unions, not-for-profit organizations, and others that sponsor benefits increasingly adopt the theory that poor lifestyle decisions that people make contribute greatly to health care costs. This is according to the Express Scripts report “9 Leading Trends in Rx Plan Management.”

“The concern with health behaviors is reflected in the programs that plan sponsors intend to implement in the coming years,” the report states. “For the first time in the [five-year] history of our survey, wellness programs were cited as the most effective measure to control overall health care costs, garnering 25 percent of the first-place mentions in a field of 11 strategies. The intended use of wellness programs in the next two years is 23 percent higher than current use, the single highest increase of any measure intended to control overall health care costs.”

Timothy C. Wentworth, Express Scripts president for sales and account management, says that “Clinicians and benefits managers know that behavior — poor diet, lack of activity, smoking and alcohol abuse — are the big factors that influence health care use and spending, but they are now realizing that people also need to listen to their doctors and stick to a treatment plan, including their prescriptions.”

The report is based on an online survey of “318 individuals with pharmacy decision-making responsibilities — such as benefit managers and benefit directors” at employers, not-for-profit organizations, and public sector unions representing 9 million covered lives. The survey, taken in the fourth quarter of 2011, includes benefit packages at companies with 5,000–50,000 covered lives. The other trends are:

  • Plan sponsors will look to online tools and mobile apps to lower costs.
  • Health care reform will raise questions about future coverage options, but only a small number of plan managers consider it the biggest challenge.
  • Employer Group Waiver Plans may soon outnumber Retiree Drug Subsidy plans as a tax advantage expires in 2013.
  • Consumer-directed health care will gain momentum.
  • Mail strategies will grow and deliver results.
  • Comprehensive management will become key to curtailing spending on specialty pharmaceuticals.
  • Drug coupons will raise cost concerns.

But it’s the attitude toward health care behavior, and the planned response, that registers with employers.

“Our employers are increasingly using online and mobile tools for employee engagement and these have a great potential to help meet goals around keeping our workers healthier and more productive,” says Tom Croyle, president of the Lehigh Valley Business Coalition on Health Care, which represents over 100,000 employees in Pennsylvania. (See our Q&A with Paul Terry, PhD.)

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.