One small health insurer sees an opportunity in the recent woes that pharmacy benefits managers have experienced. As some question where PBM loyalty lies, Independence Health Association in the Buffalo, N.Y., area wants to show that it is more

than just an HMO and is now offering to manage the pharmacy benefit for large employers. This is the first time that a health plan that is not a national player has taken such a step.

"I’ve talked to a lot of people who are not happy with their PBMs," says John Rodgers, RPh, MBA, the pharmacy director at the 360,000-member health plan. "For many reasons. Service is one of them; cost, another. I think the big issue that has cropped up even on the public scene with the attorneys general going after the big PBMs is that the PBMs are not necessarily aligned in a way that they should be with employers in terms of [seeking] savings."

Rodgers says the insurer is trying to position itself to contract with employers no matter what direction those businesses take. For instance, Independence Health wants to get some business even from companies that turn away from highly managed care to self-insure.

"To answer the question, ‘What is the difference between offering our HMO product and providing self insured pharmacy benefits?’ — we will do either, depending on the employer’s risk tolerance," says Rodgers. "One big difference in New York is that self-insuring will allow an employer to get out from under state HMO mandated benefits that can be quite costly. An employer could easily enjoy a much lower out-of-pocket pharmacy benefit cost if he elects to go self-insured."

So far, the PBM, started in January, has contracted with about 12 employers, covering about 12,000 lives. Where from here?

"We still have to build our pharmacy network a little bit more completely outside of our area," says Rodgers. "Our staffing is tied to the western New York market right now. Our intent is to really manage that before we take any huge national accounts."

Consultants are watching.

"This will help them to make some inroads and produce savings in their self-insured product lines," William P. Kelly, a consultant in Albany, tells the Buffalo News.

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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.