Payers

The FDA approved Pfizer’s respiratory syncytial virus (RSV) vaccine Wednesday; Medicare announced plans to largely cover a new class of expensive Alzheimer drugs; more states are extending postpartum coverage under Medicaid.

Insurance is by far the most important factor of whether patients followed up with treatment after getting screened for glaucoma, said Byron L. Lam, MD, professor of ophthalmology, University of Miami Miller School of Medicine's Bascom Palmer Eye Institute.

Kicking off the 2023 Greater Philadelphia Business Coalition on Health annual conference, Mark Fendrick, MD, of the University of Michigan, delivered a keynote exhorting the audience of employers and payers to implement the principles of value-based insurance design (VBID) in order to improve individual and population health and drive toward equity.

If approved by the FDA, sotatercept would be the first therapy that acts directly against the cause of the disease.

Although commercial accountable care organization populations are healthy on average, some individuals might benefit from programs for high-risk patients to mitigate high levels of health care utilization.

Study authors said the findings could inform clinicians when selecting therapies for patients with type 2 diabetes (T2D). However, an editorial found the follow-up period too short and differences between the study arms too small to be meaningful.

Oncology has been an easy area for employers to adopt biosimilars because of the rising costs in the space, said Margaret Rehayem, vice president, National Alliance of Healthcare Purchaser Coalitions. Now that multiple adalimumab (Humira) biosimilars are hitting the US market, employers should take a step back to review their current strategy around the drug.

Rebates remain very attractive for many employers, but they should push back on the reliance on rebates that may be preventing biosimilars from being added to formularies, said Margaret Rehayem, vice president, National Alliance of Healthcare Purchaser Coalitions.

Increases in Medicare Advantage market share over the past 10 years are largely caused by an increased preference for managed care among Medicare beneficiaries.

Gene therapy has the promise of being one and done, but it isn’t always that way for all patients, which leaves questions about where these therapies fit in the commercial landscape, said Charles C. Wykoff, MD, PhD, of Retina Consultants of Texas and the Blanton Eye Institute at Houston Methodist Hospital.

A study assessing factors that may determine a commercial health plan’s likelihood of covering a biosimilar found that biosimilars that are cancer therapies, used to treat children, indicated for highly prevalent conditions, or only competing against the originator were more likely to have coverage restrictions.

While employers fall on a spectrum when it comes to knowledge and understanding of biosimilars, there does remain a need to educate them, as well as for them to educate their employees, said Margaret Rehayem, vice president, National Alliance of Healthcare Purchaser Coalitions.

This quantitative and qualitative analysis highlights differences in prior authorization requirements for migraine drugs from nearly 50 managed care organizations and summarizes broad types of criteria used.

Each patient needs to weigh the benefits and risks of genetic testing for melanoma and have someone who can take the time to explain everything, including insurance risks, said Sancy Leachman, MD, PhD, professor and chair in the Department of Dermatology and director of the Melanoma Research Program at the Knight Cancer Institute at Oregon Health and Science University.

The Employer Playbook on Biosimilars highlights strategies employers can use to navigate challenges around ensuring employee access to biosimilars at the pharmacy, as well as how to respond to pharmacy benefit managers who aren’t making biosimilars available on the formulary, said Margaret Rehayem, vice president, National Alliance of Healthcare Purchaser Coalitions.

Many gene therapies promise life-changing effects, but without long-term data it remains to be seen how long the benefits last.

Payment models that align financial incentives of payers, providers, and patients can mitigate spending growth in thoughtful ways, but the details of the models matter.

Equity has to be made front and center in conversations about value assessment, otherwise all stakeholders will continue waiting for someone else to make the first move, said one panelist at the Value-Based Insurance Design Summit.

A ruling by District Judge Reed O’Connor on March 30 called the future of preventive care access into question.

Natalie S. Callander, MD, director of the University of Wisconsin Carbone Cancer Center Myeloma Clinical Program, reviewed the treatment landscape at the National Comprehensive Cancer Network (NCCN) 2023 Annual Conference.

The Protocol AC study analyzed visual acuity gains and cost if patients with diabetic macular edema started on bevacizumab, which costs less, and switched to aflibercept later, explained Jennifer K. Sun, MD, MPH, associate professor of ophthalmology and chief of the Center for Clinical Eye Research and Trials, Harvard Medical School; and chair, DRCR Retina Network.

The province of Newfoundland and Labrador and the territory of Yukon both announced biosimilar switching policies, bringing Canada to a total of 10 out of 13 jurisdictions have a policy in place.

Payers are looking to roll back on paperwork requirements for prior authorization (PA); CMS and Medicare Advantage (MA) insurers battle over new regulations; Johnson & Johnson (J&J) falls behind Pfizer and GSK for vaccine approval.

For employers, keeping members engaged with their health care is one of the key factors that leads to better outcomes, said Jeremy Wigginton, MD, vice president of health quality and innovation at Blue Cross and Blue Shield of Louisiana.