Payers

In a local market with multiple accountable care organizations and multiple Medicare Advantage plans, how do we administratively set rates that are localized enough so that they do not drive consolidation?

Kimberly Westrich, MA, vice president of health services research at the National Pharmaceutical Council, discusses the shift to a value-based system from a fee-for-service one and how the health care system can incentivize high-value care.

It’s right to acknowledge that dental, hearing, and vision are important for total health care for Medicare beneficiaries, said Melissa Andel, MPP, vice president of health policy at CommonHealth Solutions.

Daniel Wolfson, executive vice president and chief operating officer of the ABIM Foundation, speaks on factors influencing mistrust of the health care system and efforts to improve quality care.

The Alliance of Community Health Plans (ACHP) recently released its 2021 Report on Affordability. In this episode of Managed Care Cast, we speak with the organization about the steps that its payer members are taking to lower costs through offerings such as virtual-first care, remote patient monitoring, and other new products, some of which were created because of the pandemic.

As the cost of oncology drugs increases, there has been a growing pressure to manage oncology drug spend, which some payers have done by establishing preferred therapies, including biosimilars.

The different approaches to setting benchmarks for population-based payment models (empirical, bidding based, and administratively set) have unique advantages and challenges.

Implementing a proactive provider outreach program resulted in significantly more prior authorization recertifications and a reduction in time to submission.

Among many presentations during a hot topics session at the American Academy of Ophthalmology 2021 annual meeting, speakers discussed the first FDA approved therapy for thyroid eye disease and the latest in enhanced monofocal intraocular lenses (IOLs).

Emergency department utilization for nonemergent ophthalmic conditions is on the rise in the United States, but presentation types vary significantly based on patient demographics, according to 2 posters presented at the American Academy of Ophthalmology (AAO) 2021 meeting.

Uveitic macular edema is common in patients with noninfectious uveitis, and its significant burden on patients and payers warrants more specific treatment guidelines to minimize quality-of-life and economic effects.

Theresa Juday, RPh, director, Specialty Product Development, CVS Health, speaks about the barriers affecting uptake of cognitive behavioral therapy (CBT) as a first-line treatment for insomnia.

States are turning to alternative payment models to improve outcomes and reduce health care expenditures, representing a critical step forward specifically for the US maternal health crisis.

Individuals who became eligible for Medicaid through Medicaid expansion have an increased likelihood of psychiatric readmission compared with their legacy-enrolled counterparts.

On this episode of Managed Care Cast, we speak with Abi Sundaramoorthy, MD, MBA, executive vice president of clinical enterprise at Somatus, on fragmented care in chronic kidney disease, its disproportionate impact on minority communities, and the potential of value-based arrangements to address disparities and promote preventive, effective care.

There’s more interest than ever in performance-based payments as they become less novel and frightening, said Jane F. Barlow, MD, MPH, MBA.

Two posters presented at AMCP Nexus 2021 analyzed the costs of treating cytokine release syndrome and neurological events, 2 common adverse events (AEs) of chimeric antigen receptor (CAR) T-cell therapy.

Oncology drugs are a huge driver of cost, but there’s a lot of innovation happening in the space to improve care and outcomes for patients, said Michelle Booth, PharmD, director of specialty clinical solutions at Magellan Rx Management.

Panelists from a session at Asembia 2021 Specialty Pharmacy Summit in Las Vegas discussed considerations for manufacturers, specialty pharmacies, and payers entering the rare disease and gene therapy market.

Theresa Juday, RPh, director, Specialty Product Development, CVS Health, discusses how payer interest in the use of cognitive behavioral therapy for insomnia has grown in recent years.

Some policy reforms can help incentivize more use of value-based contracts, but overall an area that needs more work is value-based contracts with pharmaceutical companies, said Steven Peskin, MD, executive director, director of population health, Horizon Blue Cross Blue Shield of New Jersey.

Panelists of the opening session at Asembia 2021 Specialty Pharmacy Summit in Las Vegas address emerging shifts in specialty pharmacy, its impact on the health care system, and future implications post pandemic.

Horizon Blue Cross Blue Shield of New Jersey has been involved in a number of value-based cancer care initiatives that will be highlighted during an upcoming Asembia session, said Steven Peskin, MD, MBA, executive director, director of population health, Horizon Blue Cross Blue Shield of New Jersey.

Posters presented at the AMCP Nexus 2021 meeting reviewed the cost-effectiveness and cost per response for zanubrutinib vs ibrutinib.

The proposal to allow HHS to negotiate Medicare Part D drug prices is relatively realistic although the outcome will vary a lot drug by drug and class by class, said Melissa Andel, MPP, vice president of health policy at CommonHealth Solutions.

Physician and health policy advocates praised the emphasis on streamlining models and ending silos, but practices that invested in the Oncology Care Model (OCM) await key details.

Novel financial concepts will help to ensure sustainable access to gene and cell therapies, which may help reduce disparities, said Jane F. Barlow, MD, MPH, MBA, senior advisor, FoCUS Project, MIT Center for Biomedical Innovation, and executive vice president and chief clinical officer at Real Endpoints.

Nicole Herbst, MD, a pulmonary and critical care fellow, talks about how visitor restrictions and communication practices in intensive care units (ICUs) during the COVID-19 pandemic negatively impacted provider job satisfaction and were linked to job burnout, according to a survey presented at the CHEST Annual Meeting 2021.

The fall meeting has multiple sessions on different aspects of health disparities and addressing drug costs, including 3 sessions on biosimilars.

Periodic reinterpretation of genetic sequencing results presents a challenge for developing transparent and systematic coverage and reimbursement policies.