Expensive new drugs could drive spending in the cancer drug category by as much as 15 percent a year through 2013, according to a Medco report. That rate would place the category just behind diabetes and central nervous system treatments by 2015, according to the company’s Drug Trend Report, which tracks utilization and spending.

“New cancer drugs reaching the market are expected to double during the next several years,” says Glen Stettin, MD, Medco’s chief medical officer. With these advances, the number of U.S. cancer survivors is expected to increase by more than 30 percent — from 13.8 million people in 2010 to 18 million people a decade later.

The heightened demand for oncology drugs has fueled specialty pharmacy demand as well. The report says that interest in these specific, targeted oncologic therapies have resulted in the price of oncology drugs surging 11.5 percent during 2010. And because many of the newer treatments are oral medications or can be self-administered, the dynamics of cancer delivery are changing, with home administration growing in importance compared with the physician’s office or an infusion center.

“It’s an exciting time in the area of cancer treatment, but as these new, targeted treatments come to market, it is vital to ensure that each patient and caregiver understand the importance of adherence and the associated detailed dosing instructions,” says Milayna Subar, MD, a national practice leader in Medco’s Oncology Therapeutic Resource Center. Overall, cancer drugs constitute 47 percent of the specialty drug pipeline, with about 125 drugs in phase 3 clinical development for cancer, 38 of which are oral medications.

The report notes that cancer treatment costs under the medical benefit, rather than the pharmacy benefit, can be substantial. But many of the medication costs are “hidden” under the medical benefit and may not be as apparent to health plans and insurers as areas of drug therapy that are paid under the pharmacy benefit. However, with about 35 to 40 percent of cancer drugs in the pipeline being oral or subcutaneously administered, and with increasing emphasis on medical management, more oncology costs are likely to move under the pharmacy benefit.

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.