Use of COX-2-selective inhibitors decreased and the use of generic NSAIDs increased as formularies incorporated drug tiers, according to a study in the Archives of Internal Medicine. Enrollees in three-tier plans with arthritis and gastrointestinal comorbidities were significantly less likely to use COX-2-selective inhibitors than were patients in nontiered plans.

"Previously there had been the belief that a tiered copayment arrangement affected only whether medications were given at the generic level or brand level. But this paper showed that even among brand-name drugs, when the higher cost brands are pushed to the third level, patients don't have access to them," says Becky Briesacher, PhD, the lead investigator of the study.

The investigators found that selection of generic NSAIDs and of COX-2-selective inhibitors tends to follow copayment structure, but use of brand name NSAIDs does not. Use of COX-2-selective inhibitors decreased with two-tier coverage, while generic use increased. Forty-two percent of patients in three-tier formulary coverage selected COX-2s; 56 percent selected generic NSAIDs. Branded NSAID use remained relatively stable.

Tiered formularies that have additional incentives for preferred medications could create the potential for therapeutic compromises, according to the authors.

"There's a concern that if you put medications that people need up in the third tier, they may not get them," says Briesacher.

SOURCE: THREE-TIERED COPAYMENT DRUG COVERAGE AND USE OF NONSTEROIDAL ANTI-INFLAMMATORY DRUGS. ARCH INTERN MED. 2004; 164:1679–1684.

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.