“Physicians don’t like prior authorization,” says Steven E. Wegner, JD, MD, chairman of the North Carolina Community Care Network, made up of 15 networks with more than 3,500 physicians and 1 million Medicaid and SCHIP enrollees.

“They have to call the insurers, it’s time-consuming, and it’s frustrating trying to understand the criteria that a health plan uses to determine drug coverage.”

That sums up the exasperation providers feel when dealing with prior authorization guidelines, and that’s why a program the network began has him excited.

The network wanted to determine whether implementing an instant approval process could improve gaps in therapy for members and increase provider satisfaction. When a member tries to obtain a prescription and the pharmacy says there will be a wait while authorization is sought, members have been known to walk out of the pharmacy and not come back to pick up the prescription.

The North Carolina Medicaid proton pump inhibitor (PPI) prior authorization (PA) program determined which PPIs would require prior approval.

Providers were given three prescription options: use of a preferred PPI without any coverage restrictions; use of a nonpreferred PPI and the traditional PA process of contacting a PBM or other third-party administrator; or the use of a nonpreferred PPI, with a check box for “meets criteria.”

Checking this box bypassed the PA process. It could mean that the patient had been prescribed an approved PPI but it had not relieved symptoms, had been diagnosed with esophagitis grade C or D, or had difficulty swallowing tablets or capsules.

The researchers found that before the program started, the market share of preferred PPIs was 17.5 percent to 19.3 percent. It increased to 76.3 percent in the first month of the program. After the first 7 months of the program, the preferred PPIs lost minimal market share (7.1% percentage points). Monthly drug costs dropped from a pre-PA mean of $4 million to a post-PA mean of $1.5 million.

Not bad at all.

Monthly drug costs and market share of preferred PPIs

Pre-rebate drug cost ($ millions)

Start of prior authorization or instant approval

Preferred drugs’ market share (%)

Source: Wegner SE, Trygstad TK, Dobson LA, Lawrence WW, Steiner BD. A physician-friendly alternative to prior authorization for prescription drugs. Am J Manag Care. 2009;15(12):e115–e122.

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.