How oncologic medications are covered in state health exchanges “might lead to new definitions and standards for medical necessity,” according to a study (“Analyzing the Affordable Care Act: Essential Health Benefits and Implications for Oncology,” by the American Society of Clinical Oncology. The authors review state-required oncologic drug classes in place now with respect to range — meaning, for instance, that Health Plan X might be allowed to cover no drugs in a certain class in a certain state while Health Plan Y decides to cover eight drugs in that same state. It also looks at the average for each class and how the drugs in the classes are most commonly covered in the states.

F. Randy Vogenberg, RPh, PhD

F. Randy Vogenberg, RPh, PhD

“Given the rapid technology innovation in the oncology drug category overall, the challenge for state exchanges will be to control care cost,” says F. Randy Vogenberg, RPh, PhD, principal of the Institute for Integrated Healthcare and a member of Managed Care’s Editorial Advisory Board.

Underwriting and actuarial equivalence requirements will most likely create unintended consequences state by state regarding coverage of any specific drug, especially newer generation brand drugs, he predicts. Medical device and diagnostic advances may provide better diagnosis under medical coverage sections of the exchange, but could face the same fate as drugs.

“Off-patent generic oncologic agents will become a bulwark for most state exchange formularies in order to create some level of consistency in coverage while containing cost and creating more predictability in coverage exposure,” says Vogenberg.

“Medicaid and insurance carriers participating in Medicaid will be challenged to provide essential health coverage while not bankrupting state budgets. How essential benefits get defined more clearly and operationalized will be an important step to determining whether state exchange coverage of cancer drugs fulfills the intended promise of health care reform expansion.”

How anti-neoplastics are covered in states now
Class Examples of drugs Range Average Most common
Alkylating agents Altremine, chlorambucil, melphalan, lomustine, cyclophosphamide 0–8 6 8
Anti-angiogenic agents Lenalidomide, thalidomide 0–2 2 2
Anti-estrogens/modifiers Estramistine, tamoxifen 0–3 3 3
Anti-metabolites Mercaptopurine 0–2 2 2
Anti-neoplastics Not listed 0–52 30 52
Anti-neoplastics, other Fludarabine, leucovorin, mitroxantrone 0–6 4 6
Aromatase inhibitors, third generation Anastrozole, letrozole 0–3 3 3
Enzyme inhibitors Etoposide, topetecan 0–3 2 3
Molecular target inhibitors Erlotinib, gefitinib, everolimus, dastainib, imatinib, nilotinib, lapatinib, pazopanib, sorafenib, sunitinib 0–11 10 11
Monoclonal antibodies Rituximab 0–3 2 3
Retinoids Alitretinoin 0–3 3 3

Notes: Columns 3–5 show the number of drugs covered. The report aggregates supplemental information regarding state EHB benchmark selection, provided from CCIIO regarding the EHB proposed rule.

Abbreviations: CCIIO, Center for Consumer Information and Insurance Oversight; EHB, essential health benefit.

Source: “Analyzing the Affordable Care Act: Essential Health Benefits and Implications for Oncology,” American Society of Clinical Oncology.

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.