Payers

The government is allowing Medicare Advantage (MA) plans to delay returning hundreds of millions of dollars or more in government overpayments; a proposed new extension of the Affordable Care Act (ACA) might make birth control coverage more accessible for certain private insurance plans; a study found that students lost around 33% of their school year because of the pandemic’s educational barriers and are struggling to regain that lost time.

The Biden administration has said it would give 60 days notice before ending the public health emergency, which was set to end April 11, and the national emergency was set to end March 1.

On this episode of Managed Care Cast, we speak with Reverend Paul Abernathy, CEO of the Neighborhood Resilience Project and board member of UPMC for You, who discusses his experiences in promoting health and resiliency in trauma-affected communities, as well as challenges related to access and accessibility of care and medical mistrust.

The first of at least 8 adalimumab biosimilars has finally launched in the United States after being kept off the market for years due to settlement agreements with the maker of the reference product, Humira.

Adults with diabetes who were forced to switch from an employer-sponsored health plan to a high-deductible health plan (HDHP) were 25% more likely to require an emergency department (ED) or hospital visit for hyperglycemia, but not for hypoglycemia, than those who did not switch plans.

Amazon’s announcement of a prescription subscription service that charges a flat monthly fee instead of offering discounts on each prescription fill represents the retail giant’s latest foray into the health care space.

Jodi Fenner, senior director at Elevance Health, speaks on the key themes she presented during her session at the 2023 Health Equity Summit in San Diego, California, titled, "Promoting Health Equity through Primary Care."

N. Benjamin Fredrick, MD, of Penn State Hershey Medical Center and Penn State University College of Medicine, speaks on the key themes he presented during his session at the 2023 Health Equity Summit in San Diego, California, as well as topics related to the measurement, creation, and implementation of health equity initiatives.

Big data has valuable implications for analyzing datasets and in day-to-day clinical practice, explained Ken Cohen, MD, director of translational research for Optum Care.

According to Eli Lilly's statement, the investigational drug worked quickly, so too few patients in the phase 2 study took it for a full year.

Ken Cohen, MD, director of translational research for Optum Care, talks about the value of prior authorizations in different contexts, and how simplicity can benefit the process in some situations.

Initiatives to address social determinants of health are likely to positively change the health care landscape, and better patient education can contribute to more favorable care choices says Ken Cohen, MD, director of translational research for Optum Care.

Creating new incentive models and transparently sharing data in a way that changes behaviors are 2 ways to reduce low-value care in the health care system, explains Ken Cohen, MD, director of translational research for Optum Care.

Patients with epilepsy on Medicaid insurance of Black, Latino, and Native Hawaiian and Other Pacific Island ethnicity were associated with lower odds of being on newer, second- and third-generation, antiseizure medications compared with White individuals.

Black Americans with multiple myeloma face disparities in incidence of disease, survival outcomes, and use of evidence-based treatment, which may be exacerbated by socioeconomic factors.

The FDA’s approval of lecanemab for Alzheimer disease is very important, but there will remain significant challenges around pricing and access that will need to be addressed to deliver on the promise the therapy actually represents, said Alvaro Pascual-Leone, MD, PhD, of Harvard Medical School.

The lecanemab decision follows the controversial 2021 approval of aducanumab, which led to tight coverage restrictions for monoclonal antibodies directed against amyloid for the treatment of Alzheimer disease.

In the last 2 years, half of women reported needing mental health services compared with only 35% of men. Women who needed mental health care cited provider availability and cost, especially for those who are uninsured, to be 2 major barriers to receiving care.

Michael Thompson, president and CEO of the National Alliance of Healthcare Purchaser Coalitions (National Alliance), addressed the current state of health equity strategies in the workplace and how employers can better address inequities in their benefit designs, programs, and policies in the near future.

The addition of adalimumab biosimilars to formularies can help accelerate realized savings as the blockbuster drug Humira faces competition from multiple biosimilars, including 1 approved interchangeable biosimilar.

The top 5 pieces of content published on AJMC.com relating to reimbursement issues included 2 on the significance of a California law giving Medicare beneficiaries access to expert oncology care; other articles looked at the work involved in value-based care models and CMS news.

The top content published in The American Journal of Accountable Care® (AJAC) covered redesigning health care, value-based care, and novel payment models, like the ACO REACH model.

In 2022, the most-read articles published in Evidence-Based Oncology™ included the latest updates in cancer treatments, the promises and challenges of technology, and a look at the shifting landscape of care delivery.

Biosimilars are a wonderful option for patients, but the growing number available can be challenging to manage when different payers prefer different agents, said Susan Sabo-Wagner, MSN, RN, OCN, executive director of clinical strategy for Oncology Consultants of Houston, Texas.