With a growing population, the prevalence of systemic lupus erythematosus (SLE) cases in the United States is expected to rise. Datamonitor compiled epidemiologic prevalence data for seven countries — the United States, Japan, France, Germany, Italy, Spain, and the United Kingdom. The largest increase in SLE cases is expected here in the United States, especially in the population most affected by SLE, namely women ages 15–44.

Coincidentally, the FDA approved a new medication for SLE, belimumab (Benlysta), on March 9.

“There hasn’t been a drug aimed at the pathogenesis of lupus until now,” says Sandra C. Raymond, president and CEO of the Lupus Foundation of America.

Raymond advises clinical executives at health plans that patients with lupus “finally have a treatment that targets the disease. Many drugs used in rheumatoid arthritis were tested for lupus in clinical trials, but they mostly did not work in lupus.”

The clinical studies in support of the approval for Benlysta hinted at a “steroid-sparing effect,” she notes. “In people with lupus, high doses of steroids have been used to tamp down the symptoms over long periods.

“But the negative effects of corticosteroid use include bone fractures, osteoporosis, and various bone replacements.” If long-term corticosteroid use can be avoided, insurers may save money in the long run.

She hopes that the drug will not be considered as a high-tier addition to the insurer’s formulary. Raymond points out that “lupus patients eventually go see the specialist — the rheumatologist — and the rheumatologist, not the primary care physician, is going to decide if the drug is appropriate for the patient — or not.”

Modest rise projected in lupus cases worldwide

The Centers for Disease Control and Prevention (CDC) is conducting a comprehensive study of the prevalence and incidence of lupus. The study includes all populations affected by lupus and almost all forms of lupus. Findings will be available early in 2013.

Source: Datamonitor, 2011

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.