Ted Slafsky, MPP & Robert Chapman, MD

In an era of rapidly escalating prices, the 340B drug discount program remains one of the few checks to keep medicine and medical care accessible to the underserved. Contrary to the recent column, "Payers Must Develop Strategies To Overcome 340B Hurdles," it is not being exploited by participating hospitals.

If it were, where exactly is the money?

Paul Terry
President and CEO, HERO

 A few days ago, I went to the “Poke-stop” in my small town of Waconia, Minnesota, (population 11,490) to learn why I was losing my Pokémon “gym battles” and, more importantly, to survey the growing numbers of twentysomethings exploring my community’s parks and landmarks. I met a group of 15 Waconians for the first time, and they were excited about describing how Pokémon Go had increased their activity levels, their awareness of our community’s history, and their engagement with others.

Jonathan Gavras, MD
Chief Medical Officer, Prime Therapeutics

Our country is in crisis. We have an epidemic on our hands that crosses geographic boundaries, socio-economic status, gender, and many other categories. According to the American Society of Addiction Medicine, drug overdoses kill nearly 50,000 Americans each year. The media is certainly putting a microscope on it. Legislators are acting on it. Every stakeholder in the medical delivery chain is analyzing it–and I encourage physicians and other prescribers to take a look at their role in the problem.

Aiden Spencer
CureMD

Paper or plastic? Debit or credit? Netflix or Amazon? These are the kind of choices we are asked to make everyday. They are not, though, the type of decisions that keep us up at night.

Paul Terry
President and CEO, HERO
Lessons we’re learning from both companies and communities show that it takes a revolutionary mindset to advance a culture of health. Looking at the color of the food in your cafeteria just might be the best place to start.
Ted Slafsky

Contrary to the highly misleading picture painted by critics, the 340B drug discount program is working as Congress intended and helping millions of underserved Americans receive better healthcare every year.

The pharmaceutical industry has gone to great lengths to misconstrue how the program functions in an effort to vilify safety-net hospitals. These are the urban and rural facilities across the country that care for all patients, regardless of their ability to pay.

Michael Flanagan
Michael Flanagan

Uncertainty regarding health insurance exchanges is not going away. Changing enrollment deadlines and newly insured populations have brought challenges to payers and providers. Success will require staying competitive on price, network quality, and access.

Princeton’s Uwe Reinhardt, PhD, renowned health care economist, sits down with Managing Editor Frank Diamond to discuss the economic effects of the Affordable Care Act, wellness programs, and the state of health care in the United States in general.

Craig Keyes
Craig Keyes

I saw my doctor last month for an annual physical. I cannot imagine a better primary care physician; he’s so thorough, so kind. After an exhaustive review, he said all seemed pretty much “ship shape,” but he had to add one dig: “Hey, I was glad to hear you finally went for your screening colonoscopy. Thing is … I can’t find any evidence that it actually happened. No claim, no entry into the electronic medical record, nothing. Did you end up having the procedure?”

Busted!! It’s true that I went to have the procedure, and I shared this with my doctor. What I didn’t tell him was that I left before it was performed.

The U.S. offers the highest advances in medicine and technology, yet only 55% of patients receive nationally recommended guidelines of care for their health needs. There are many contributing factors, but gaps in care that go unattended top the list.

The vast majority of Part D plans follow a tiered cost-sharing structure with incentives for members to use less expensive generic and preferred brand-name drugs. Cost-sharing has increased since 2006, but the Kaiser Family Foundation reports in “Analysis of Medicare Prescription Drug Plans in 2011 and Key Trends Since 2006” that there was barely a change between 2010 and 2011.” The foundation reports that since 2006, median cost sharing for a 30-day supply of nonpreferred brand name drugs in stand-alone prescription drug plans (PDPs) increased by 42 percent, from $55 to $78. Preferred brand costs increased 50 percent, from $28 to $42. But since 2010, cost sharing has been stable.

About half of PDP enrollees and over 75 percent of MA-PD plan enrollees are in plans that charge 33 percent coinsurance for specialty drugs. Compared to 2009, this share is down modestly for PDPs but up substantially for MA-PD plans. In contrast, only 4 of the 35 national or near-national PDPs charged a 33 percent coinsurance rate for specialty tier drugs in 2006.

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.