The great debate part II: should managed care rely on cost sharing to manage big-ticket biologics?
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Biological Products↗
Biomedical subjects
Mark Zitter
Publications and source records attributed to Mark Zitter.
Managing drugs for rare genetic diseases: trends and insights.
Managed care organizations generally pay for expensive drugs that treat rare genetic diseases because few patients have these conditions, the conditions are often life threatening, and the benefit design mandates coverage. In most cases, the cost-control measures and management restrictions applied to many other specialty pharmaceuticals do not make sense for the orphan drugs used to treat extremely rare genetic conditions because treatment alternatives usually are lacking for rare conditions (e.g., Gaucher's disease) and because the per member per month costs for truly rare conditions are low. The increasing number of biologic and injectable therapies for more common conditions, however, is prompting managed care decision makers to manage these new therapies more actively. There is a potential that treatments for rare disorders will be swept up in this broad-based response. This article provides definitions, background, and stakeholder perspectives on this topic and describes recent trends and challenges in health system management of exceedingly rare genetic diseases. The author suggests that current protocols are appropriate for managing rare and ultra-rare diseases, and that applying more active management practices to less rare diseases is neither efficient nor productive; in fact, it may be counter-productive.
Drug Costs↗
Defining the great debate.
Treatment guidelines offer a credible approach to MCO management of specialty pharmaceuticals by basing decisions on the best available scientific evidence. Drawbacks to using guidelines include lack of available evidence, bias on the part of the expert team, a lack of currency, and difficulties in implementation. Treatment guidelines can and often do serve, along with product labeling, as the basis for reimbursement and usage rules as specified in MCO medical policies. The relationship between provider-oriented guidelines and payment criteria varies by payer, with implications for care quality, cost, and access. Increased awareness of the advantages and disadvantages of using treatment guidelines to shape prescribing policies for specialty pharmaceuticals may lead to worthwhile non-product-specific discussions within MCOs about sources and methods used in medical policy development.
Drug Labeling↗
Health economic considerations in the management of type 2 diabetes.
The number of therapeutic options for people with type 2 diabetes is increasing. Large-scale clinical trials have delineated the health benefits of tight glycemic control with these interventions, including the reduction of long-term diabetes-related complications. These long-term complications compromise quality of life and ultimately account for mortality in most patients with diabetes. Despite the high price tag of managing the long-term complications of hyperglycemia, few economic incentives have been presented for investing in intensive glycemic control. Recent cost-benefit analyses, however, provide insight into the major cost drivers that yield a short-term return on investment for preventive measures. This article highlights cost-effective measures that have been successfully utilized in the managed care setting to simultaneously improve health and economic outcomes of diabetes within the first few years of implementation.
Blood Glucose↗