Unbiased Analysis of Today's Healthcare Issues
How does ICER plan to determine whether health plans offer fair access to pharmaceuticals? I summarized their approach last year as outlined in their white paper titled “Cornerstones of ‘Fair’ Drug Coverage: Appropriate Cost-Sharing and Utilization Management Policies for Pharmaceuticals.” Last month, final protocol for their “Barriers to Fair Access Assessment“. While the approach follows…
Prior authorization is a pain. A paper by Howell et al. (2021) found that the total cost of various utilization management schemes is $93.3 billion of which physicians devote $26.7 billion worth of time to navigate utilization management systems. Payers would argue that prior authorization helps to control costs and stop the prescribing of unnecessary…
Medicare Part D plans have begun using preferred pharmacy networks in order to steer their beneficiaries to lower cost pharmacies. A key question is, does this work? A paper by Xu et al. (2022) aims to answer this question using 2011-2016 data. that compares Low Income Subsidy (LIS) Medicare beneficiaries and non-LIS beneficiaries. LIS beneficiaries…
Many countries allow private plans to administer health insurance benefits but with restrictions on premiums and with the potential for risk adjusted government payments based on the health of a health plan pool For instance, Belgium , Germany, Israel, the Netherlands and Switzerland all have mandatory health insurance schemes; Ireland and Australia have voluntary health…
Are narrow networks a good thing or a bad thing? The first thing you need to know is what is a “narrow network”. Narrow networks is an informal terms which basically means that your health plan either places restrictions over the providers you are able to see and/or you certain providers that are out of…
Specialty drugs have delivered significant improvements to patient health, but oftentimes they pay be expensive. To try to insure that these treatments are used appropriately, some health plans impose a utilization management tool known as “prescriber requirements” where only certain types of physicians may prescribe a drug. While this may be useful for some complex…
Last fall, ICER published a white paper titled “Cornerstones of ‘Fair’ Drug Coverage: Appropriate Cost-Sharing and Utilization Management Policies for Pharmaceuticals.” To paraphrase, ICER’s goal is to limit access restrictions (e.g., cost sharing, coverage limitations, prescriber restrictions, step therapy) when a drug is deemed to be cost effective. How will they do this? Their Barriers…
How do you get your prescription drugs? For most people, it involves going to your local pharmacy and picking up your pills. But what if the drugs you needs are infused treatments that have to be administered at a physician’s office? Typically, you just show up at a physician’s office and it’ll be ready for…
Prior authorization is a requirement that health plans require physicians to obtain plan approval in order to prescribe a patient a given medication. Prior authorizations may be put in place to insure medications are not used inappropriately or for payers to try to reduce cost. While prior authorization may help save money, delays in the…
What are digital therapeutics? What evidence is needed to support their value? How should we pay for them? I participated in Academy of Managed Care Pharmacy (AMCP) Partnership Forum: Digital Therapeutics which took place in September 2019. The findings from that forum are presented in a recent JMCP article. An excerpt from the article is…