Payers

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.

The suits are on behalf of providers and health insurance customers and involve some famous plaintiffs' attorneys.

The implementation of the Affordable Care Act and its resulting market turbulence has not created the operation challenges for payers that was expected, according to a report from athenahealth, Inc.

This week The American Journal of Managed Care launched its new Managed Markets News Network, featuring the top stories in managed care and interviews with industry experts.

The guidance comes after advocacy groups and members of Congress complained of widespread violations of the Affordable Care Act's requirement that all forms of birth control be covered without a co-payment, not just the low-cost methods. The action also responds to recent reports that payers have balked at requests for BRCA testing even when indicated.

Since the introduction of the Oncology Care Model, oncologists have raised numerous questions as they weigh whether to apply for participation.

The pharmaceutical industry has learnt its lesson from the pushback that Gilead faced over the price of its hepatitis C drug, Sovaldi. The lack of a price discussion prior to the introduction of the regimen washed-out the excitement over a "cure" for the disease.

A general session at the Community Oncology Conference, Community Oncology 2.0, Moving Forward on Payment Reform, was a panel discussion that saw participation by 2 providers and a payer.

With a focus on improving quality while maintaining the cost of care, providers and payers are evaluating various payment models that could improve patient outcomes using evidence-based treatment at lower costs to the healthcare system.

As patents on some of the most lucrative medicines began to expire, many companies shifted money to rare-disease drugs, knowing that those medicines cost less to develop and will face limited competition.

When the first National Comprehensive Cancer Network Guidelines were developed 20 years ago, even the participating members who were there at the beginning were skeptical they would be able to come to an agreement and build something lasting.

A new analysis published by the RAND Corporation suggests strategies that the pharmaceutical industry could offer payers as they try to cover the front-loaded cost of newer breakthrough drugs.

Starting with a contract that works for both parties involved is the best way to ensure payers and providers will work together, said Craig Thiele, MD, chief medical officer of CareSource.

The Patient Access Network or PAN Foundation formed more than 10 years ago, partially in response to the Medicare Part D benefit. It helps patients meet cost-sharing requirements across dozens of diseases, including 25 in oncology; Evidence-Based Oncology, a publication of The American Journal of Managed Care, invited PAN Foundation President and CEO Dan Klein to discuss its role in immuno-oncology.

The goals of the new CMS Oncology Care Model align very nicely with what payers want, according to Ira M. Klein, MD, MBA, FACP, national medical director, clinical thought leadership, office of the chief medical officer, Aetna.

A lengthy report published by the Kaiser Family Foundation predicts widespread market disruption if ACA premium subsidies are lost under King vs. Burwell. Adverse selection, insurers exiting markets, and higher rates are just some of the possibilities.

With the March 4 Supreme Court hearing on King v. Burwell looming, big business is stepping up to defend the healthcare reform law.