Insurance

Aetna is selling its Medicare Part D prescription drug unit to WellCare Health Plans; Seema Verma, administrator of CMS, defended Medicaid work requirements, saying they are not intended to kick people out of the program; an experimental tuberculosis (TB) vaccine demonstrated 54% protection in a clinical trial.

This week, the top managed care news included comments to several proposals from CMS; Medicare advocates say voters will be motivated by healthcare cost concerns during the midterm elections; research showed diabetes drug dapagliflozin, an SGLT2 inhibitor, reduces risks of major cardiovascular events.

The in-home visit gives the pharmacist a unique perspective on the medication experience of the member, allowing them to compare discharge information and Part D claims information to the medications present in the home, as well as assess adherence and discover discrepancies by having the member walk them through when and how they take their medications each day.

Readmission rates for Medicare patients with 6 major diseases were statistically higher among for-profit hospitals compared with nonprofit or government hospitals, according to a new study.

This instrumental variables analysis estimates that Medicare would realize $362 million in annual savings if all patients with newly diagnosed low back pain were managed conservatively.

Advocates for keeping Medicare as it is were joined by a well-known pollster to discuss that voters are concerned about out-of-pocket costs, including what they pay for prescription drugs, as the 2018 midterm elections approach.

Medicare will ease up on annual readmission penalties for safety-net hospitals; the House of Representatives has passed a bill prohibiting pharmacy gag clauses, sending the bill to President Donald Trump's desk; the Creating and Restoring Equal Access to Equivalent Samples (CREATES) Act of 2018 would reduce federal spending on prescription drugs by $3.3 billion from 2019 to 2028.

Community Oncology Alliance (COA) submitted formal comments to CMS in support of proposed changes to the 340B Drug Discount Program and site-neutral paymnts put forward in the Hospital Outpatient Prospective Payment (HOPPS) rule. However, they also submitted comments warning against proposals to introduce new third-party middlemen to the Part B system.

CMS’ proposed rule described strong financial results from low-revenue ACOs, as well as ACOs in risk-bearing tracks, but it mostly ignored the success of small, rural providers in ACOs.

Heart failure hospitalization has been a target for accountable care organizations seeking to find ways to cut costs from the healthcare system. But it remains to be seen how many of the estimated 2 million patients would gain access to the device if it received an expanded indication and payer coverage.

AARP and other groups reacted strongly to reports that the pharmaceutical industry was using efforts to combat the opioid crisis to roll back an agreement to close the coverage gap in Medicare Part D.

Coverage of our peer-reviewed research and news reporting in the healthcare and mainstream press.

CMS' Medicare Shared Savings Program proposal would make substantial changes to the benchmarking methodology for accountable care organizations.

Every week, The American Journal of Managed Care® recaps the top managed care news of the week, and you can now listen to it on our podcast, Managed Care Cast.

Research has shown nonemergency medical transportation can be essential for patients in rural areas, as well as the poor, elderly, and chronically ill. In a Health Affairs blog post, authors from CareMore Health show how the company has found success with Lyft after a pilot program it ran in 2016.

This week, the top managed care news included medical groups asking CMS to halt or slow down its plans to cut physician reimbursement for evaluation and management services; the Senate weighs a package of bills to combat the opioid epidemic; new research shows the Affordable Care Act pushed the uninsured rate down to 10%.

Not only do pharmacy benefit managers profit thousands of percent using spread pricing, but the spreads are growing; support for Medicare for all is growing among Democrats in Congress, but it's still unclear how such a drastic chage would impact the complex American healthcare system; while precision medicine has great potential, it still has far more failures than successes, but that isn't usually discussed.

Over 14,600 comments poured into CMS to meet a deadline to comment about proposed changes to its 2019 physician fee schedule for Medicare, with many physician organizations and individuals asking the agency to halt or slow down its plans to cut physician reimbursement for evaluation and management services. While some groups cheered some of the changes—such as broader coverage for telehealth and other digital monitoring—most expressed many concerns.

Community Oncology Alliance (COA) has submitted formal comments to CMS Administrator Seema Verma on the 2019 Medicare Physician Fee Schedule.

Over 200 patient and provider groups have written to CMS, saying that proposed consolidation of evaluation and management billing codes will adversely affect the sickest Medicare patients and the physicians that treat them.

In 2016, the Next Generation Accountable Care Organization (ACO) model generated a net savings of $62 million to Medicare, representing a 1.1% net reduction in Medicare spending. In a webcast with the Accountable Care Learning Collaborative, CMS Administrator Seema Verma called the results a strong start and offered a look at what's in the future for the model.

Nebraska voters will decide on Medicaid expansion in November; a medical watchdog has called for a stop to a clinical trial for sepsis treatment; Medicare Advantage insurer Clover Health is expanding its health plans to 6 new markets.

Among Medicare beneficiaries, the relationship between fragmented ambulatory care and subsequent emergency department visits and hospital admissions varies with the number of chronic conditions. Check out our website’s new table/figure pop-up feature! Click on the name of a table or figure in the text to see it in your browser.

Coverage of our peer-reviewed research and news reporting in the healthcare and mainstream press.

Using lower-cost generic drugs that are as safe and effective as the brand-name versions could have saved more than $900 million in Medicare in 2016, according to research published in JAMA.

As skilled nursing facilities handle more complex care, the need arises for physician input before sending patients to the hospital. Study findings reported this month in The American Journal of Managed Care® show that using telemedicine for this purpose can lead to fewer hospitalizations and savings for Medicare.

Three federal officials discussed the status of research, payer coverage, and referrals for the National Diabetes Prevention Program, as well as the rollout of the Medicare program for eligible seniors.

Every week, The American Journal of Managed Care® recaps the top managed care news of the week, and you can now listen to it on our podcast, Managed Care Cast.