Payers

Limiting access to non–vitamin K antagonist oral anticoagulants through step therapy and prior authorization may exacerbate current underuse of anticoagulants and increase the risk of stroke in patients with newly diagnosed atrial fibrillation.

The involvement of pharmacy benefit managers (PBMs) in 340B is the “colliding of 2 worlds,” said Ted Okon, MBA, executive director, Community Oncology Alliance.

Although there is a paucity of data of switching among biosimilars of the same reference product, the few studies published support the safety and effectiveness of transitioning patients from one biosimilar to another.

FAIR Health published the findings of their 15-year analysis of Lyme disease, including an increase in private insurance claim lines in rural and urban areas from 2007 to 2021.

Even though the Oncology Care Model (OCM) ended on June 30, 2022, there are some improvements that practices should continue implementing, said Susan Escudier, MD, FACP, vice president of value-based care and quality programs, Texas Oncology.

Senator Joe Manchin, D-West Virginia, ended his opposition to the Inflation Reduction Act of 2022, paving the way for reductions in some Affordable Care Act subsidies and action on drug pricing; AbbVie’s Allergan agreed to pay more than $2 billion in opioid settlements; a study found vitamin D supplements do not reduce bone fracture risk.

As part of the investigation into pharmacy benefit managers (PBMs), the Federal Trade Commission (FTC) should delve into how PBMs are impacting and fueling drug prices and set up guardrails to protect Americans, said Ted Okon, MBA, executive director, Community Oncology Alliance.

In retina surgery, obtaining prior authorization is an extra burden, and a delay in treatment for some of these patients could mean loss of vision, said Sabin Dang, MD, ophthalmologist with The Retina Institute.

Elaine Siegfried, MD, professor of pediatrics and dermatology, Saint Louis University Health Sciences Center, speaks on step edits and other barriers limiting access to biologic, topical, and other medications for the treatment of atopic dermatitis (AD).

Patients who experienced Clostridioides difficile infection had increased risks of mortality and hospital readmission, as well as greater length of stay and total hospital charges.

Stakeholders from Horizon Blue Cross Blue Shield of New Jersey discuss new ways to address management gaps for chronic behavioral health conditions, including a new integrated care model that puts community behavioral health providers in charge of overall care.

Until recently, ophthalmologists in the United States have had no experience with biosimilars, despite the availability of biosimilars for bevacizumab, which is commonly used off label for ophthalmic conditions.

While prior authorizations are put in place to ensure appropriate use of expensive therapies, they create a substantial burden for clinicians and patients, said Sabin Dang, MD, ophthalmologist with The Retina Institute.

Results looking at acceptance of minimal residual disease (MRD) status found that 60% of participants “would change at least one decision based on an MRD result,” and 54% would use both MRD status and disease risk to make decisions.

Although technology is allowing for earlier detection of eye conditions, lack of reimbursement and insurance coverage remain major barriers to widespread use, explained speakers at the American Society of Retina Specialists 40th Annual Scientific Meeting.

During a session at the American Society of Retina Specialists 40th Annual Scientific Meeting, speakers highlighted research into the opportunity cost of vitreoretinal surgery and the impact the pandemic had on retinal procedures and reimbursement in early 2020.

This study attempts to identify the sources of the significant 2.5-fold variation found in home health expenditures, a possible indicator of inefficiency and waste.

On this episode of Managed Care Cast, we find out about efforts by a managed Medicaid health care plan in Southern California to bring prevention and intervention mental health services to schools in response to a worsening crisis among America's children and adolescents.

Four large Medicare Advantage insurers manage access to expensive physician-administered drugs with a combination of prior authorization, step therapy, and Part D formulary design.

The oncology space has seen successful adoption of biosimilars thanks to processes and formulary decisions driving conversion rates.

Drug survival rates of biologics in patients with psoriasis were shown to be associated with their effectiveness and safety profiles, in which incidence of psoriatic arthritis, nail involvement, and other factors were indicated as effect modifiers.

At AHIP 2022, Vanessa Bobb, MD, PhD, FAPA, vice president of Behavioral Health & Medical Integration at CDPHP, moderated a session on real-world study findings showcasing cost and quality benefits of value-based contracting in behavioral health. Bobb discusses findings of the study and how value-based programs can be better leveraged in mental health and substance abuse care.

Simplified treatments and patient-specific and systemic interventions can reduce nonadherence in patients.

In the second of 2 parts, Nathan H. Walcker, MBA, CEO of Florida Cancer Specialists & Research Institute (FCS), discusses what he’d like value-based care to look like going forward. CMS ended the Oncology Care Model (OCM) yesterday after 6 years and has invited practices to apply for a successor model, the Enhancing Oncology Model.

Panelists of a keynote session at AHIP 2022 discuss how lessons learned from investment and infrastructure in public health during the COVID-19 pandemic can be leveraged to promote equitable care for all Americans and prepare for the next public health emergency.