John A. Marcille

John A. Marcille

Pharmacy in managed care has edged its way forward as a major issue of the day, thanks in part to the long-overdue discussion of whether (and/or how extensively) to provide drug coverage for people in the Medicare program. The fact is, we rely increasingly on pharmacy to deal with health care problems and to forestall greater costs in other components of the system, such as inpatient services and emergency rooms.

Pharmacy coverage should not be decided separately from overall health coverage. Everyone who has medical coverage (which should be everyone, though heaven knows, we're a long way from there and the road is rocky — see our TennCare report) should have drug insurance. Not providing it is like not providing surgical coverage: "Need a CABG? You're on your own, Jack."

As usual, the devil is in the details. Senior Editor Michael D. Dalzell lays out a lot of those details in our cover story, "The Double-Edged Sword," which describes the difficulties in devising a copayment scheme that will simultaneously control costs by preventing waste and enhance health by promoting adherence (formerly compliance, a word that seems to have been reassigned to the Office of Inspector General). To my mind, this is one of the most vexing problems in managed care today, and while a strategic approach is what's needed, most plans, reacting to steep increases in pharmacy costs, are making tactical moves that may not get at the roots of the problem.

Many people are giving this issue serious thought, and one of the most respected is J. Lyle Bootman, Ph.D., the new president of the American Pharmaceutical Association and the subject of our popular Question & Answer feature. That the professional pharmacists association has chosen an economist as its 1999 leader shows that the profession as a whole — and not just its managed care component — is attentive to the interaction of cost and care.

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.