Managed Care spotted the danger posed to health plans by drug coupons almost immediately (/archives/2011/12/copayment-coupons-undermine-formularies), but insurers are not the only ones who should be concerned, according to an opinion piece in the August 28 edition of the New England Journal of Medicine.

The coupons encourage consumers to use more expensive brand-name drugs by making the effective copayments equal to copayments for generics. They are an assault on formularies, and on the bottom lines of health insurers and pharmacy benefit managers. They are not such a good deal for patients, either, in the view of Joseph S. Ross, MD, and Aaron S. Kesselheim, MD, JD, MPH, authors of the NEJM article ( aptly titled “Prescription-Drug Coupons — No Such Thing as a Free Lunch.”

“Some coupons can be used once, and others more than once,” they write. “But we found few that offered savings for more than a year. Once a coupon program ends, patients with chronic diseases face copayments for these brand-name medications that are higher than those for generic alternatives. By that point, however, patients may have developed loyalty to the particular brand or may be skeptical about switching away from a medication that they perceive as effective — or they may not even be aware of alternative therapies.” Physicians have not really helped either because of “clinical inertia” or simply not knowing the cost implications of coupons.

Ross and Kesselheim look at coupons advertised in March on the Web site, finding 374 brand-name drugs for a wide range of conditions. They report that “62% of coupons … were for brand-name medications for which lower-cost therapeutic alternatives were available.”

The larger implications are, “The more that patients use drug coupons to obtain brand-name medications when lower-cost alternatives are available, the more expenses will rise for their insurers. A predictable response from the insurers would be to raise coverage rates for all patients.”

Actually, insurers have other options, as we reported last year (/archives/2012/5/how-combat-pharma%E2%80%99s-costly-coupon-programs), though they’re not always easy to implement and may not be entirely effective.

Linda Cahn, a health care lawyer writing in Managed Care in May 2012, said that the “simplest approach is to uniformly change the copayments for each drug tier and thus create a greater differential between the copayments.”

Large health plans might want to consider creating two different covered-drug lists “or an open and closed formulary — and informing members that they will have to contribute a different premium depending on which list or formulary they choose....”

Drowning in a sea of coupons

Availability of lower-cost alternatives to brand-name drugs for which coupons are offered

Source: “Prescription-Drug Coupons — No Such Thing as a Free Lunch,” New England Journal of Medicine,” Aug. 28, 2013

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.