Insurance

Some generic drugs may actually cost Medicare Part D beneficiaries more out-of-pocket than brand-name drugs because brand-name manufacturers can offer discounts that generic drug makers cannot pay.

This week, we recap the top managed care news from the first half of 2019, including outcomes from some of the biggest diabetes trials, research into the annual Medicare wellness visit, and an experimental treatment in Parkinson disease.

Leaders of the Senate Finance Committee have discussed a deal to limit drug prices in Medicare; Louisiana Governor John Bel Edwards will annouce a "Netflix model" deal with Aseuga Therapeutics that will increase access to an effective Hepatitis C drug, AbbVie has annouced a $63 billion transaction agreement to acquire Allergan.

Since 2007, the number of enrollees without low-income subsidies who had spending above the catastrophic threshold has more than doubled, reaching 1 million enrollees in 2015, 2016, and 2017.

With the expected surge of aging Americans over the next few decades, states are trying to prepare for a wave of Alzheimer disease and dementia, which carries with it an enormous societal burden, extracting a toll on families and caregivers, and impacts state Medicaid budgets. In response, nearly every state is turning to Alzheimer action plans to try to cope with what is coming in the years ahead.

Value-based care has been a big prerogative of CMS for the last decade, and it's not going away, Brian Kern, a lawyer with Frier Levitt, told Amy Ellis, director of quality and value-based care at Northwest Medical Specialties.

Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs) cover more than 32 million lives and have been found to save money and improve quality in past research, but a new study in Annals of Internal Medicine is calling their success into question.

Differences in cancer care spending and utilization between Medicare beneficiaries receiving chemotherapy in hospital outpatient departments versus physician offices vary by service type.

Results were presented recently at the 79th Scientific Sessions of the American Diabetes Association.

The Community Oncology Alliance (COA) has filed its alternative to CMS' Oncology Care Model (OCM) with the Physician-Focused Payment Model Technical Advisory Committee.

As increasing attention is paid to the cost of healthcare, there are growing efforts to steer patients toward high-value care. New research published in JAMA Network Open compared teaching hospitals with nonteaching hospitals to determine the total cost for common conditions.

The Oncology Care Model (OCM) is pushing cancer centers and cancer programs to make the changes they knew were needed to improve care delivery and patient experiences, said David Ortiz, OCM program director at Montefiore Einstein Center for Cancer Care.

New ratings for Medicare health plans should spur a renewed focus on patient experience.

Creating a healthcare system that prioritizes a well-informed consumer and rewards improvements in quality requires overhauling the current system. Through a series of programs and initiatives, CMS, under Administrator Seema Verma’s leadership, is trying to fix some of the issues that plague the current US health system and make accessing care challenging for patients.

The long time between when a performance period ends and when the report comes out in the Oncology Care Model (OCM) can make it difficult to measure the impact specific changes are making, said David Ortiz, OCM program director at Montefiore Einstein Center for Cancer Care.

A study of readmission rates by primary care providers (PCPs) finds a lack of variation and calls into question implementing pay-for-performance programs that incentivize or penalize PCPs for readmissions.

The Trump administration is backing off a proposal that would have allowed private Medicare plans to refuse to pay for certain drugs for chronic conditions that experience steep price hikes; 5 more states have sued Purdue Pharma, alleging the company llegally marketed and sold opioids; bariatric surgery may offer more benefits for adolescents than adults.

The Oncology Care Model (OCM) has set off a ripple of change in cancer care that extends beyond the patients who are in the model, said David Ortiz, OCM program director at Montefiore Einstein Center for Cancer Care.

Even though Northwestern Medicine is projected to sustain a loss in the new Bundled Payments for Care Improvement Advanced, it plans to participate because doing so will position Northwestern Medicine as best possible to manage future challenges in episodes of care.

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.

This week, the top managed care news included HHS announcing a finalized rule requiring the disclosure of drug prices in television ads; a report finding high satisfaction with employer health coverage despite the cost; a study finding heart failure is surging among young adults.

Triage pathways can transform practices and save practices and CMS money by keeping people out of the emergency department and hospital, said Ray Page, DO, PhD, president and director of research at The Center for Cancer and Blood Disorders.

Hospital prices of privately insured patients are more than twice the price that Medicare pays, according to a new report from RAND and supported by the Robert Wood Johnson Foundation, the National Institute for Health Care Reform, the Health Foundation of Greater Indianapolis, and participating employers.

Tennessee is set to become the first state to transition its Medicaid program to a block grant; a federal judge has blocked cuts to Medicare rates for 340B hospitals but did not grant permanent injunction; Senator Elizabeth Warren has unviled a plan to combat the opioid epidemic that would spend $100 billion over 10 years.

Jeff Patton, MD, chief executive officer of Tennessee Oncology, offers his reaction to CMS' proposal to ease restrictions on how Part D managed the 6 protected classes of drugs.

During World Health Care Congress 2019, healthcare stakeholders from around the globe convened to discuss all things healthcare, ranging from Medicare for All to social determinants of health.

During a session at World Health Care Congress 2019, Senator Bill Cassidy, MD, offered his alternative to Medicare for All, which is modeled after the Children’s Health Insurance Program, and discussed other healthcare issues on his radar.

Basit Chaudhry, MD, PhD, founder of Tuple Health, explains why it's important to evaluate the adequacy of the novel therapy adjustment under the Oncology Care Model (OCM).

During a session at the National Association of Accountable Care Organizations (ACOs), top performing ACOs shared lessons learned and best practices for ensuring compliance with quality measures while keeping the patient at the forefront.

Crescent Moore, PharmD, PhD, BCPS, senior consultant, BluePeak Advisors, discusses how CMS is planning on implementing care coordination programs in Medicare.