About 99 percent of workers in plans sponsored by employers have a prescription benefit. And while the majority don’t have to pay a separate prescription deductible or have an annual out-of-pocket limit that applies only to prescription drugs, about 13 percent do, according to the 2012 Kaiser/Health Research & Educational Trust (HRET) Employer Health Benefits Survey.

A breakout by plan type shows that 17 percent of covered workers in PPOs had a separate drug deductible — higher than in HMO and POS plans in 2012. PPO plans also had the highest percentage of workers with separate out-of-pocket limits for prescription drugs (13 percent).

For workers in plans with a separate prescription deductible, nearly 70 percent report that the deductible was applied to every drug tier. The average deductible was $145.

About 11 percent of workers with coverage for prescription drugs are in plans with a separate prescription drug annual out-of-pocket limit: The average was $1,722 in 2012.

The survey found that in general, workers at companies with 35 percent or more workers earning no more than $24,000 a year are more likely to face high deductibles than those at higher-wage companies. Specifically, 44 percent of covered workers at businesses with many low-wage workers face an annual deductible of $1,000 or more, compared with 29 percent of those at employers with many high-wage workers. Across all employers, 34 percent of covered workers face a deductible of that size, including 14 percent with deductibles of at least $2,000 annually.

The Kaiser/HRET annual survey of employers provides a detailed look at trends in employer-sponsored health coverage, including premiums, employee contributions, cost-sharing, and other relevant information. The 2012 survey included 3,326 randomly selected public and private businesses with three or more employees.

Workers have drug coverage and a separate prescription drug deductible

Workers have drug coverage and a separate annual out-of-pocket limit for prescription drugs

Source for both: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2005–2012

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.