Unbiased Analysis of Today's Healthcare Issues
When we think of utilization management (e.g., prior authorizations, step edits), we often think payers only use these for higher cost branded products including biologics. Generic drugs should have low cost sharing and limited utilization management. One question, however, is whether payers’ utilization management practices for biosimilars mirror those of biologic products, or small-molecule generics,…
That is the news according to a report in Healthcare Dive. Blue Shield of California…will drop CVS Caremark as the sole manager of its pharmacy benefits. In Caremark’s place, Blue Shield of California will contract out the job to five separate companies…Blue Shield of California, or BSCA, expects to save $500 million a year from…
If you guessed manufacturers, you would be incorrect. At least that is according to a new study by Mattingly et al. (2023) in JAMA Health Forum. Using a sample of the 45 generic drugs with >$100m in Part D and used by >1m beneficiaries, the authors found that: …Medicare Part D spent $11.8 billion for…
Historically, physician administered specialty pharmaceuticals are covered by a patient’s medical benefit and oral medications are covered by the pharmacy benefit. Increasingly, however, specialty pharmaceuticals are being covered by pharmaceutical benefit. Does this make a difference? Does medical vs. pharmacy coverage of drugs impact patient access? A recent paper by Levine et al. (2023) aims…
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…
In recent decades, drug prices have risen. To offset this cost, pharmacy benefit managers have negotiated increasingly large rebates which drug manufacturers pay health insurers. PBMs argue that rebates help keep net drug prices down. Manufacturers argue that PBMs want higher list prices so they can negotiate larger rebates. Patients may not like rebates if…
Pharmacists are typically paid for dispensing drugs. They receive a fee to cover the price for acquiring a given drug and a dispensing fee. In general, however, pharmacists are not paid based on patient outcomes. Will that change? Troy Trygstad (2020) argues that value-based reimbursement for pharmacists through accountable pharmacy organizations (APOs) may be the…
Value-based insurance design (VBID) is a simple concept. In short, interventions that provide high-value should be covered with little cost sharing; treatments with low-value should be covered with higher rates of cost sharing or in some cases perhaps not even covered at all. A paper by Cohen et al. (2017) aims to see how far…