Anticipating the future: how the emergence of innovative biologic agents impacts benefit design, utilization, and provider relations.

OBJECTIVE: To review the impact of biologic therapies on commercial and government payers. SUMMARY: Biologic agents, a mainstay in the treatment of cancer and immunopathologic conditions, are being used for an expanding number of indications, and new agents are being developed for use in many other diseases. These biologic agents have the potential to improve patient quality of life and the overall quality of care with minimal risk of adverse events. Many of these agents require administration via nontraditional methods and are priced at a premium, compared with existing therapies. Consequently, both commercial and government payers must devise strategies that simultaneously ensure access to these agents while minimizing their overall cost impact. Several tools are available to payers to achieve these goals, including aggressive formulary management, drug-use evaluation, and the use of specialty pharmacy services. CONCLUSION: With appropriate planning and oversight, the value of biologic therapy can be optimized in the managed care setting.

Availability of nutrition services for Medicaid recipients in the northeastern United States: lack of uniformity and the positive effect of managed care.

OBJECTIVES: To evaluate third-party coverage of medical nutrition therapy for the Medicaid population, among whom obesity is a common health problem, and to compare coverage in managed care Medicaid programs with that in fee-for-service state Medicaid programs. METHODS: Fifty-four Medicaid organizations in 14 states were surveyed by telephone and asked about their provision of nutrition counseling to members. RESULTS: Overall, similar percentages of state Medicaid programs and Medicaid managed care organizations (MCOs) reimbursed for nutrition counseling; significantly more Medicaid MCOs reimbursed for this service for treatment of obesity alone. Analysis of Medicaid MCO responses by plan size failed to show a difference in the nutrition services offered. CONCLUSIONS AND RECOMMENDATIONS: Nutritionist consultation, an inexpensive and effective intervention for treatment of obesity, is not uniformly available to Medicaid patients. The inclusion of managed care in Medicaid has increased access to this service in the northeastern United States. We propose that all Medicaid recipients should have access to visits with a registered dietician or certified nutritionist either as part of a defined benefit structure or through a disease management program for obesity.