Payers

Melinda C. Aldrich, PhD, MPH, associate professor in the departments of medicine, thoracic surgery, and biomedical informatics at Vanderbilt University, discussed recently updated lung screening guidelines from the American Cancer Society and the importance of equity across populations as new guidelines are developed.

While the first ustekinumab biosimilar, Wezlana, was approved in October 2023, a settlement with Johnson & Johnson (J&J) will keep it off the market until 2025, preventing competition, and causing purchasers to pay substantially more for the agent.

The most popular reimbursement content of 2023 included coverage of the shift from the Oncology Care Model to the Enhancing Oncology Model, reactions to the 2024 Medicare Physician Fee Schedule, and concerns around denial of services in Medicare Advantage plans.

While the Enhancing Oncology Model is the successor of the Oncology Care Model, it includes some very real challenges for participating practices, explained Lalan Wilfong, MD, senior vice president of payer and care transformation at The US Oncology Network.

A one-size-fits-all approach to alternative payment models (APMs) often isn’t very fair to community practices, said Miriam Atkins, MD, FACP, president of the Community Oncology Alliance.

Coverage from The US Oncology Network Payer Transformation Summit, held September 27-29, 2023, in Atlanta, Georgia.

This article examines how CMS’ adjustment for social risk factors affects the Medicare Advantage Star Ratings and the type of contracts affected by the adjustment.

In the phase 3 EV-302/KEYNOTE-A39 clinical trial, the antibody-drug conjugate enfortumab vedotin plus PD-1 inhibitor pembrolizumab nearly doubled both median overall survival and progression-free survival compared with chemotherapy.

David Fajgenbaum, MD, MBA, MSc, cofounder of Every Cure, shared that the organization is able to reduce clinical trial costs to $1 to $5 million per drug trial, and that clinical trials are not always necessary to expand a drug's indication.

The bipartisan bill would help lower Medicare costs and improve quality of care, according to the National Association of ACOs.

A new report from AHIP shows that Medicare Advantage outperformed traditional Medicare on several clinical quality measures, including preventive screenings. However, debate continues over these plans’ cost efficiency and impact on the financial sustainability of rural hospitals.

The commercial market got slightly less competitive while the Medicare Advantage market got a little more competitive, but both markets remain highly concentrated.

Activity to regulate pharmacy benefit managers (PBMs) has started in the states and is trickling up to the federal level, said Ted Okon, MBA, executive director of the Community Oncology Alliance.

Leading payer and health system stakeholders reviewed literature and shared insights on the value of real-time continuous glucose monitoring (rtCGM) in type 2 diabetes (T2D) population health.

The company is changing the way it prices prescription drugs and providing more transparency, which has been one focus of pharmacy benefit manager regulation efforts.

The past year has offered new hope for patients with lower-risk myelodysplastic syndromes. Besides imetelstat, which has an FDA deadline for action of June 2024, the agency approved luspatercept, which has a different mechanism of action.

A new report highlighting the twin pressures hospitals have faced over the last 18 months shows that as reimbursement delays and denials increased and cash and investments decreased, operating expenses have risen sharply.

If finalized, these proposals will generally take effect on January 1, 2025, unless otherwise noted.

As part of updates to its standard formulary, CVS Caremark has removed Amjevita and now prefers Hyrimoz and an unbranded biosimilar.

Health plan type highly influences the likelihood of biosimilar uptake, with low-flexibility insurance plans more likely to have patients who either switched to a biosimilar or were initiated on a biosimilar.

A simulation study estimated the impact of biosimilar substitution on total cost of care (TCOC) and provider financial performance in the final performance period of the Oncology Care Model.

The American Medical Association (AMA) is continuing to urge Congress to stop the impending 3.4% cut to physicians, and other organizations also weigh in on the pros and cons of the 2024 Medicare Physician Fee Schedule.

Tirzepatide is already approved to treat type 2 diabetes, and is now approved for chronic weight management in adults with obesity or overweight with at least 1 weight-related condition.

This 2022 survey of Medicare accountable care organizations (ACOs) shows significant growth in non-Medicare value-based contracts and in contracts with downside risk.

Formulary restrictions can create treatment barriers for patients with atrial fibrillation, including unnecessary delays in treatment and prescription abandonment, with vulnerable populations at greater risk.

The Enhancing Oncology Model is trying to address a number of the systemic challenges oncology faces without giving practices the tools and resources they need, said Nicolas Ferreyros, managing director of policy, advocacy, and communications, Community Oncology Alliance.

This study demonstrates a method for understanding the effects of drug spending in the design of alternative payment models.

Changes in the medication therapy management (MTM) program willl require planning on how to best fund this program in a way that drives medical cost savings.

This retrospective cohort study of rural hospitals found that Medicare Advantage penetration increased substantially from 2008 to 2019 and was associated with greater hospital sustainability.

The Medical Group Management Association offers an analysis of pending legislation that could help health care practices better serve patients.