Pharmacy benefit managers – the middlemen who negotiate drug purchases for insurers and large buyers – are coming under growing scrutiny and criticism both in Connecticut and nationwide for their role in the sharp rise of prescription drugs. The third-party companies, called PBMs for short, originally processed claims for pharmacies, but now are hired by Medicare, Medicaid and commercial health plans to manage pharmaceutical benefits. Their reach is broad: they choose what drugs are covered by insurance; negotiate purchasing deals with drug makers; determine co-pays for consumers; decide which pharmacies will be included in prescription plans; and decide how much pharmacies will be reimbursed for the drugs they sell. The growing legions of PBM critics, who include state Comptroller Kevin Lembo, pharmacists and their trade and service organizations, say that the industry is helping drive the unrelenting rise in prescription drug prices and insurance premiums.
PBMs, Lembo’s office and state pharmacists say, use a variety of tactics to capture cash from consumers, payers and pharmacies. One is spread pricing, where they pay the pharmacy less for a prescription than a payer gives them, sometimes even forcing the pharmacist to take a loss.
The rate of denials by the state’s largest managed care insurers of requests for mental health services rose nearly 70 percent between 2013 and 2014, with an average of about one in 12 requests for prescribed treatment initially rejected, a new state report shows. At the same time, the proportion of enrollees in the largest managed care companies who received outpatient or emergency department care for mental health doubled, from an average of 9.4 percent in 2013 to 20.8 percent in 2014, according to an analysis of the 2015 Consumer Report Card on Health Insurance Carriers in Connecticut, issued by the state Insurance Department. The percentage of members who received inpatient mental health care also doubled, although it remained low, with most companies providing inpatient services for less than .5 percent of all enrollees. The rise in rejections by the state’s 10 largest indemnity managed care companies – private health insurers, not including Medicare or Medicaid — came as state officials focused on improving mental health outreach and treatment, in the wake of the Sandy Hook school shooting in December 2012. The managed care organizations include companies such as Aetna Life Insurance Co., Anthem Health Plans, CIGNA Health and Life Insurance Co., and UnitedHealthcare Insurance Co.
As we open the book on 2016, here are a few things to watch for in the field of women’s health and well-being. In no particular order, from the Office of Healthcare Prognostication—a department I just made up—comes these predictions for the new year:
1 • The use of mobile health apps, or so-called “health wearables,” will increase, according to the American College of Sports Medicine’s 10th annual survey on fitness trends. Already, the adoption of smartphone health apps has doubled in the last two years, from 16 percent in 2013 to 32 percent of consumers saying they have at least one health app on their mobile device. 2 • Beyond measuring one’s fitness, health care in general will begin a “shift into the palms of consumers’ hands,” according to PwC’s 2015 Health Research Institute’s annual report. It’s happening already in primary care and the management of some chronic diseases, though programs such as Omada Health’s online program called Prevent are pushing into fields such as behavior modification.