News about financing the massive Medicare Part D program is good these days — or at least better. The Medicare prescription drug benefit is expected to cost $30.5 billion this year, CMS Administrator Mark McClellan told the Senate Special Committee on Aging on Feb. 2. That's 20 percent less than the government's previous estimate of $38.1 billion. Estimated costs have decreased in part because drug plans are offering lower premiums than expected and, says McClellan, because enrollees are shopping for the best deals. The lower premiums stem, in part, from stronger-than-expected competition among Medicare Advantage plans.

Operating the program from 2006 to 2015 is now expected to cost about $678 billion, a huge number, but one that is 8 percent lower than the $737 billion projected cost released last summer.

The news gets better on the micro, as well as the macro, level. The average monthly premium for an enrollee is expected to be about $25 per month. In August, the average was projected to be $32.20 per month. That is a significant difference for people on a low fixed income.

Still, McClellan acknowledged that there have been snags in rolling out Part D. Reports about the confusion enrollees experience in selecting the right plan for themselves have been rampant. In addition, senators want assurances that the Part D plans reimburse states and pharmacies that have paid for beneficiaries' medications in a timely manner. "We make no excuses for these problems," McClellan told the committee. "They are important, they are ours to solve, and we are finding and fixing them."

Which is to say that Medicare Part D is far from out of the woods. In fact, the next month or so will be critical. The Kaiser Family Foundation says that 45 percent of eligible people have enrolled in the program, 29 percent do not plan to enroll, and 23 percent are unsure. Meanwhile, the May 15 deadline for enrollment looms.

"A substantial number of beneficiaries are already enrolled, but a lot turns on what those who are on the fence decide to do between now and May 15," says Drew Altman, president and CEO of Kaiser Family Foundation.

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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.