Payers

In the year since New Jersey regulators approved OMNIA, the state's health insurance market has experienced the same upheaval seen elsewhere: the number of options on the exchanges has shrunk from 5 to 2.

Professor R. Keith Campbell, MBA, BPharm, CDE, now retired from Washington State University College of Pharmacy, highlights the clinical advantages of Afrezza based on the evidence as well as his personal perspective.

Democratic lawmakers who signed a letter to Mylan this week say that the practice of offering coupons masks the high drug prices that are paid by commercial health plans. The practice is not allowed in Medicare or Medicaid.

While Mylan has steadily increased the price of EpiPens since 2007, the uproar from consumers is more recent. This suggests that for several years, payers masked the cost of the product, but that has changed with the popularity of high deductible plans.

Payers are making investments in care coordination to halt the overuse of services and medication. Certified diabetes educators (CDEs) are ideal candidates for this role, since so much of high healthcare spending is due to chronic disease.

There are signs that smaller providers, in particular, are not moving toward value-based reimbursement at the same pace as larger healthcare stakeholders.

A statewide all-payer claims database would permit more insight into what’s happening with cost and quality of providers, and possibly transform healthcare payment, explained Karen van Caulil, PhD, president and CEO of the Florida Health Care Coalition.

According to Kelly J. Clark, MD, MBA, president elect of the American Society of Addiction Medicine, payers and pharmacy benefit managers can aid in patient access to the medication they need to treat addictive disease by ensuring an evidence-based prior authorization protocol, just as they would for a patient with a chronic disease.

Coverage from Patient-Centered Diabetes Care, April 7-8, 2016. Presented by The American Journal of Managed Care and Joslin Diabetes Center.

Spurred by the migration to new payment methodologies and a rapidly evolving competitive landscape, many managed care companies have launched venture and innovation programs. This article provides a high-level evaluation of the universe of model options accessible to payers who are interested in such programs.

The growth of clinical pathways in cancer care brings opportunities to improve quality and control cost, but there are frustrations, too. Physicians want to retain some freedom and are pushing back against the administrative jungle from multiple payers, according to a special issue of Evidence-Based Oncology, a publication of The American Journal of Managed Care.

On the first day of The Community Oncology Conference: Innovation in Cancer Care, held in Orlando, Florida, April 13-15, 2016, oncologists discussed how their practices are coping with the transition toward quality- and value-based reimbursement.

Did MannKind misjudge consumer demand, or are barriers from payers to blame for Afrezza's woes? A feature outlining the misfortunes and future plans for the only inhaled insulin on the market.

GAO found that the first challenge to improving hospital safety can be getting good data about one's own institution.

Mann spent $1 billion of his own money to bring Afrezza to market. The Los Angeles Times reported he died in Las Vegas.

The study, while small, suggests a scalable solution that would allow payers address diabetes prevention and health disparities.

Researchers found that physicians often seized the "opportunity" to start dialysis if patients were in the hospital for other illnesses.

The new rule has been issued just as states are cracking down on the practice of balance billing patients who take steps to use in-network hospitals, only to be balanced billed anyway if they are seen by a provider not on their health plan.

Sessions on obesity and the role of technology in disease management will be part of the annual gathering of stakeholders, presented by The American Journal of Managed Care, April 7-8, 2016, at the Teaneck Marriott at Glenpointe in Teaneck, New Jersey.

Depending on one's point of view, the 340B prescription drug program keeps safety net hospitals afloat or serves as a profit center at the expensive of community providers. Three leading voices-Rena M. Conti, PhD; Peter B. Bach, MD, MAPP; and Michael Kolodziej, MD; recommend reforms in the new issue of Evidence-Based Oncology, a publication of The American Journal of Managed Care.

At the first annual conference of the Institute for Clinical Immuno-Oncology on October 1, 2015, in Philadelphia, the discussion revolved around integrating immuno-oncology into clinical practice and programs that assist with patient access to these treatments.

Providers and payers came together to discuss challenges and share success stories as they adapt to the changing healthcare realm.

Payer—provider teams presented updates on their cost-saving pilot projects and looked to the future of these models in oncology care.

With various healthcare stakeholders having different wants and needs from the healthcare system, meetings that bring all parties together in one room are important, according to Suzanne F. Delbanco, executive director of Catalyst for Payment Reform, and keynote speaker at the spring live meeting of the ACO and Emerging Healthcare Delivery Coalition.

New resources are being directed toward precision medicine, particularly in cancer care. With that in mind, Evidence-Based Oncology, a publication of The American Journal of Managed Care, devotes its current issue to articles and commentaries on this growing field.

The recent mergers between healthcare payers continue the trend of consolidation that has swept the healthcare industry since passage of the ACA.

In oncology, the shift from a "companion diagnostic" to a "companion therapeutic" paradigm is in high gear. While the noise and confusion is leading many payers to avoid coverage, they can benefit by proactively taking steps to integrate precision oncology to better manage quality, access, and cost of cancer care.

The link between getting patients to take medication correctly and keeping down healthcare costs is strong enough that adherence is being tied to reimbursement for healthcare providers. A study published recently in The American Journal of Managed Care examines connections at the health plan level between good plan-level adherence, lower rates of disease complications, and lower medical spending.

Jennifer Malin, MD, medical director for oncology at Anthem, explains how both physicians and payers struggle with the high cost of some cancer treatment drugs.

The report found a 6.5% increase in the compound annual growth rate during the 5-year period leading up to 2014.