Developing state-level programs to care for complex populations, PTAC backs 2 new alternative payment models, and a cancer gene profiling test may open doors to new targeted therapies.
Welcome to This Week in Managed Care, I’m Laura Joszt.
Caring for Complex Populations
The National Governors Association (NGA) has released a road map to guide states to establish complex care programs.
The road map comes after 4 years of working with 10 states and Puerto Rico as they implemented their own state-level solutions that target high-need, high-cost patients who are high utilizers of the emergency department and other costly settings of care.
NGA identified 4 components key to building and implementing a complex care program:
Develop internal resources, build stakeholder partnerships, and conduct environmental scans
Build a theory of the case, identify the target population, and design a way to track and evaluate the approach
Develop and implement a delivery and payment model
Track implementation, evaluate the program, and communicate the findings
NGA’s program was born out of successful programs already in place across the country, such as those being run by Hennepin Health in Minnesota and the Camden Coalition of Healthcare Providers in New Jersey.
Last year, Renee Murray of the Camden Coalition, explained the hotspotting technique the organization was using to identify and care for complex patients.
One model is an episode-based payment model in end-stage renal disease. The model targets the first 6 months of dialysis and was given a full recommendation. The other payment model was a capitated payment model from the American Academy of Family Physicians, which was recommended for limited-scale testing.
Proposals that failed to receive recommendation from PTAC include an APM for the initial therapy of newly diagnosed patients with organ-confined prostate cancer, billing for annual wellness visits at rural health clinics, and a proposal for bundling maternity and newborn care.
Opening Doors to New Targeted Therapies
The first-of-its-kind comprehensive companion diagnostic test for solid tumors, FoundationOne CDx, not only provides patients with the ability to be matched with a therapy, but opens the door to development of new targeted therapies.
Stuart Goldberg, MD, chief scientific officer of Cota, told The American Journal of Managed Care® (AJMC®) in an interview that the test marks a new era in precision medicine.
He said, “What you’re trying to look for is: is there a gene that is altered or mutated, and is that gene, so-called, actionable? Do we have a pill or targeted therapy to turn that gene off? And … maybe by turning off that gene you can slow down the progression of the cancer or maybe even put the patient in remission.”
The test also has potential benefits for patients with less common types of cancer and will allow doctors to refer patients for clinical trial participation if there are no therapies currently available and it is discovered that a lot of patients have a certain mutation.
Top Managed Care Story
Finally, for the past 2 weeks, AJMC®’s readers have been voting on what they thought was the biggest managed care story of the year. It was a close race, and the top 5 stories included President Donald Trump ending the Affordable Care Act cost-sharing reduction subsidies to insurers and the Senate failing to pass ACA repeal and replace legislation.