Two of the nation's largest HMOs have weighed in against covering Viagra, Pfizer's anti-impotence pill that has taken the world by storm. Calling Viagra a "lifestyle drug," Aetna U.S. Healthcare said it would pay for it only if employers purchased special coverage. Kaiser Permanente flat-out refused coverage, saying the drug is "not medically necessary."

Some such decisions have not sat kindly with subscribers. One group filed a class-action suit against Oxford Health Plans and other "John Doe" insurers, claiming that coverage denial breaches their fiduciary responsibility under the Employee Retirement Income Security Act. The lead plaintiff says he suffered from diabetic-related impotence until Viagra restored his sexual function.

While HMOs have been deciding which Americans will feel the sensation, Viagra itself has become a worldwide sensation. A Japanese travel agency has put together Viagra tours to Hawaii for its countrymen who want the drug. In Canada — Viagra is months away from approval there — men have flocked to Niagara Falls, N.Y., where pharmacies are filling up to 20 Canadian prescriptions a day. And Viagra samples mysteriously disappeared at an Israeli parliamentary committee meeting while experts testified about the drug's safety.

Pfizer is aware of safety concerns — at least 16 men who took Viagra have died — but says complications, not the drug itself, are to blame. Viagra's label warns against combining use with nitroglycerin; early reports suggested many of the men had heart disease.

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.