White vs. Brown vs. Clear Bagging

In 2020, spending on specialty drugs was $265 billion; this constituted 49.6% of total prescription drug expenditure. To combat rising costs, payers have turned to white, brown and clear bagging as well as approaches to restrict the site of care where patients receive specialty drugs. What are these “bagging” policies, what are the pros and…

Do narrow networks save money?

According to a recent paper by Wallace (2023), the answer is ‘yes’, but it does so in a highly inefficient manner. Using 2008-2012 Medicaid data from the New York State Department of Health, the author find that: Leveraging the random assignment of over 50,000 Medicaid enrollees in New York, I present causal evidence that narrower…

ICER’s 2022 “Barriers to Fair Access Assessment” Protocol

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…

How can physicians earn a ‘gold card’?

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…

Preferred Pharmacies in Medicare Part D

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…

How ICER will conduct it’s “Barriers to Fair Access” Assessment

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…