A study in the Journal of the American Medical Association suggests that HMOs' increased use of cost-sharing to soften prescription drug expenses may have actually increase overall medical costs over the long term. The authors contend that increased out-of-pocket prescription drug spending forces some members to stop taking medications that would otherwise prevent illness.

Rising drug prices have led many health plans and pharmacy benefit managers to institute higher copayments and deductibles and to lower benefit caps. The intent often is to discourage patients from taking medications that may not be medically necessary — but as the authors point out, that assumes informed decision-making on the part of patients.

The study examined the impact of Quebec's decision to implement a universal drug benefit in 1996. To fund the program, the province introduced a deductible and a 25-percent copayment for everyone; previously, prescription drugs had been available at no cost to the elderly and to low-income residents.

Analyzing claims data, the authors found that use of essential drugs dropped 9 percent in the elderly, and 14 percent by low-income residents. In both groups, adverse effects and emergency visits associated with reduced adherence to prescription regimens more than doubled.

From this, the authors speculate that short-term pharmacy savings may be much smaller than the added cost of treating illness down the road.

The government did achieve its aim, as use of less-essential prescription drug products dropped 15 percent among older people and 22 percent in the low-income group. There were few adverse effects associated with these reductions.

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.