What health plans will spend on traditional drugs is falling, caused by the wave of patent expirations for blockbuster drugs. Express Scripts, a pharmacy benefit manager, reports that spending for traditional drugs will decline through at least 2015. In its 2013 Drug Trend Report, the company expects spending to be –1 percent in 2013, –1.7 percent in 2014, and –1.4 percent in 2015. Utilization is expected to remain stable, but insurers will see even more savings as patents expire for Cymbalta (duloxetine) and Lidoderm (lidocaine).

Three traditional drug classes, however, merit watching: diabetes agents, agents that treat attention deficit disorders, and antidepressants.

The report says that for the second year in a row, medications used to treat diabetes were the most expensive therapy class per member, per year (PMPY). And while spending is expected to increase over the next few years, the magnitude of change is expected to slow. The report identifies new dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 (GLP1) competitors, and new insulins, including dulaglutide, still experimental, with once-weekly dosing that has shown promise in clinical trials, as possible new causes of spending increases.

Attention deficit disorder agents as a class had a drug expenditure increase of 14.2 percent in 2012, driven by increased utilization among adults and by shortages. That number is expected to be only 4.4 percent this year as the market stabilizes and generic competition increases. By 2014, however, expect an increase of 10 percent and then 8.6 percent in 2015. Express Scripts expects an increase in utilization among young and middle-age adults.

In contrast to these two classes, antidepressant spending should decrease. The report expects a 4.7 percent decline with the expiration of the Lexapro patent. Although there are some new drugs in the pipeline, like levomilnacipran and edivoxetine, they are expected to compete with existing drugs of the same type rather than to dramatically change utilization of existing drugs. Expect spending on antidepressants to be down 8.7 percent in 2014 and down 6.5 percent in 2015.

Amid falling drug expenditures generally, exceptions to the rule

Three drug classes worth watching

Source: Express Scripts, Drug Trend Report 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.