April 2016

Predictive biomarkers are revamping drug development and breathing new life into old and failed drugs. But this re-thinking of what works, in who, and why raises questions about cost and accessibility. Precision may be pricy.

Michael D. Dalzell
Michael D. Dalzell

When Alexander Graham Bell phoned it in, so to speak, who could have predicted that it would eventually lead to IBM’s Watson Health tackling medication adherence with state-of-the-art analytics?

Jan Greene

Information overload from a flood of new diagnostics forces insurers to ramp up prior authorization and utilization review.

Joseph Burns

Manufacturers are starting to offer significant rebates in exchange for preferred status on an insurer’s formulary.

Thomas Reinke

California and other states have put monthly caps on out-of-pocket medication expenses. But the caps might shift some costs over to premiums.

Joseph Burns
The Value of Drugs: It Is Not About the Money!
Interview by Peter Wehrwein
Ana D. Vega, BS
Paul P. Meola, BS
Julio Ramon Barcelo Jr.
Heidi M. Perez Ruiz, BS
Stephanie A. Oh, PharmD

Legislation & Regulation
It seems like Godot may arrive sooner. Seven years after the biosimilar law was enacted, stakeholders are losing patience with the FDA.
Richard Mark Kirkner
Legal Front

A Harvard Law School group is among those that have taken action.

Ed Silverman

Managed care organizations need to work on several fronts if they are to improve patient adherence. Limiting out-of-pocket costs is one place to start.

Richard G. Stefanacci, DO
Tomorrow’s Medicine

Sarepta’s eteplirsen functions like an RNA patch so functioning dystrophin gets made. Other drugs like it may be used to treat Ebola and other viral infections.

Thomas Morrow, MD
Biologics in Development
Katherine T. Adams
Cancer Watch
Organized oncology isn’t ready to give up on ASP+6 payment for Medicare Part B drugs. But experimentation with value-based pricing has some supporters.
Peter Wehrwein

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.