The rate of increase for medical costs and prescription drugs are projected to decline in 2008, according to the Segal Health Plan Cost Trend Survey. This marks the fifth consecutive year of slower rates of increases for medical claims.

Meanwhile, the rise in the costs for prescription drug coverage has slowed at about the same pace, declining by nearly 9 percentage points, since their high of 19.5 percent in 2003. This downward trend is occurring across all managed care plan types. The report says that more claims for generic drugs have been filed, due to patent expiration and PBM efforts.

Nearly 25 percent of survey respondents forecasted that the cost of medical claims and perscription coverage for PPOs will be about 10 percent of the total PPO budget. Four years ago, 3 percent of respondents forecasted that such costs would be under 10 percent for 2004. Nearly one-third of respondents say that prescription drug costs for 2008 would be less than 10 percent, up from 3 percent of respondents in the 2004 survey.

Projected medical and prescription drug trends, 2007–2008

*Trend projections were derived by proportionally blending medical plan trends and freestanding prescription drug trends.
**HDHPs are defined as those where the deductible is at least the minimum health savings account (HSA) level required by the Internal Revenue Services.
***Open access PPOs and POS plans are those that do not require a primary care physician gatekeeper referral for specialty services.
****MA plans, part of the Medicare program, can be FFS plans, HMOs, PPOs, or special needs plans.
Source: 2008 Segal Health Plan Cost Trend Survey.

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.