Payers

The analysis of adults with low income enrolled in Medicare Advantage (MA) or traditional Medicare (TM) indicates that increasing enrollment in MA may not advance health equity in the Medicare program.

The Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) Model provides the next great opportunity in moving a health care payment system toward paying for value and rewarding preventive care and keeping patients healthy.

Medicaid managed care network adequacy standards exhibit significant heterogeneity across regions and specialties, potentially creating large variations in health care access and quality.

As part of its inquiry, the Federal Trade Commission (FTC) will demand that the 6 largest pharmacy benefit managers (PBMs) submit records and answer questions regarding their business practices.

Research presented at EULAR 2022 demonstrated the pharmacokinetic equivalence of a low-concentration version of the adalimumab biosimilar SB5 and a high-concentration version.

Surveys of patients and oncologists found discrepancies between patient experiences and oncologist perceptions of those experiences during a nonmedical switch to trastuzumab biosimilars.

The organizations that can take on 2-sided risk are usually bigger and that’s not always better for health care, said Jayson Slotnik, partner, Health Policy Strategies, Inc.

Alignment of incentives in the United States do not always support the use of biosimilars or other lower-cost alternatives, said Sonia T. Oskouei, PharmD, BCMAS, DPLA, vice president of biosimilars at Cardinal Health.

Data to be presented next week during the American Society of Clinical Oncology Annual Meeting show that for every 10% increase in public welfare spending, there was a 4.55% narrowing of the 5-year overall survival (OS) disparity between Black and White patients with cancer.

As biosimilar competition heats up in the United States, payers have more tools at their disposal to manage these agents.

Many payers are not familiar with digital therapeutics, indicating the need for better education among payers, said Jayne Hornung, chief clinical officer, pharmacy, MMIT.

Thanks to flexibilities provided by the American Rescue Plan, 4 states announced Wednesday they will expand Medicaid coverage to 12 months postpartum, joining others who have already adopted similar measures.

The findings highlight the significant financial burden of sickle cell disease.

The tools we need to achieve long-term stability for community providers and ensure better outcomes for rural Americans are available, and CMS can help us utilize them.

Across commercial insurance, Medicare, and Medicaid populations, oncology is the top category of spend, and the drug pipeline has increasing specific and complex therapies.

On this episode of Managed Care Cast, we speak with one of the authors of a paper published this month in Health Affairs about the utilization of substance use disorder treatment (SUD) services between 2010 and 2019, and why more needs to be done to get more individuals into treatment.

The report details totals paid to hospitals by private insurers and providers and compares the sums with a Medicare benchmark.

While 2023 is a big year with at least 7 adalimumab biosimilars expected to come to market, 2024 will be even more important because all the products will be on the market and formulary decisions can be made, said Sonia T. Oskouei, PharmD, BCMAS, DPLA, vice president of biosimilars at Cardinal Health.

Gene therapies in the pipeline to treat hemophilia will be very expensive, but they also seem to be very efficacious, and multiple could hit the market between now and 2024, said Ray Tancredi, RPh, MBA, CSP, divisional vice president, specialty pharmacy development and brand Rx/vaccine purchasing, Walgreens.

While CMS has started making changes to address health equity through policy and payment models, commercial plans are waiting to see the outcomes before they follow suit, said Jayson Slotnik, partner, Health Policy Strategies, Inc.

Experts evaluated the future of cell and gene therapies in the United States and offered insights on potential value-based payment models for these treatments.

Biosimilar adoption can be accelerated or stymied depending on actions taken by the managed care space, explained Sonia Oskouei, PharmD, vice president, biosimilars, Cardinal Health, during a session at Asembia’s Specialty Pharmacy Summit.

In a session at the 2022 Asembia Specialty Pharmacy Summit, Jayne Hornung, chief clinical officer at Managed Markets Insights & Technology (MMIT), outlined factors driving payer hesitation when it comes to covering prescription digital therapeutics.

UPMC Health Plan, RxAnte, and Mosaic Pharmacy Services outlined how they are operating a value-based pharmacy care management program within Community HealthChoices, Pennsylvania’s managed Medicaid long-term services and supports (LTSS) program, at a recent conference.

Experts from The US Oncology Network discuss the future of value-based cancer care, and what practices can do as the Oncology Care Model expires.