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This Week in Managed Care: April 21, 2017


This week, the top managed care stories included a new rule from CMS to end abuse on the Affordable Care Act insurance exchanges; a study that indicates type 2 diabetes may possibly be reversed; and CareMore unveils a new care model that takes place in the dentist's chair.

CMS moves to end abuse on the insurance exchanges, digital health programs make news, and some seniors in California will be able to get their blood pressure checked at the dentist.

Welcome to This Week in Managed Care, I’m Laura Joszt.

CMS Issues New ACA Rule

CMS took steps this week to stabilize the individual insurance market, with a new rule that should improve the risk pool. The changes come after several national insurers stopped selling on the exchanges set up by the Affordable Care Act.

Highlights of the new rule are:

  • Open enrollment for 2018 will last just 6 weeks, from November 1 to December 15
  • Consumers will need more documentation if they try to join the exchange after changing jobs or moving
  • Those who drop coverage must repay what they owe if they try to rejoin the exchange with the same insurer

The rule comes as UnitedHealth announced that its revenues and profits increased after pulling back from the exchanges. UnitedHealth has asked for a repeal of the ACA’s health insurer tax and more flexible state-based markets.

Read more about the CMS rule.

Digital Health for Diabetes

Digital behavioral health providers are gearing up to offer the Diabetes Prevention Program through Medicare, starting in January 2018. This week, the provider Noom, which offers outcomes-based pricing, was the first digital provider to win full recognition from the CDC, a key step for reimbursement.

The digital provider Virta health, which offers online coaching in a low carbohydrate diet, was featured in The New York Times after early results from a clinical trial showed participants were able to lower A1C levels while taking fewer medications.

A co-author of the study, Sarah Hallberg, DO, MS, of Indiana University Health, wrote on AJMC.com how the study could change the paradigm for people with type 2 diabetes, from expecting to manage their disease to reversing it.

Hallberg writes: “With the increasing cost of healthcare, including $1 of every $3 in Medicare going to the treatment of type 2 diabetes and its comorbidities, we have to look for solutions. In doing so, we must be willing to acknowledge that there have been past shortcomings in both dietary recommendations and treatment goals. Our patients deserve the opportunity to gain control of their health. They want more than just another prescription or procedure.”

Chronic Disease Care at the Dentist

CareMore, the integrated health delivery system for people in Medicare Advantage and Medicaid, this week unveiled a new care model that could alter thinking about who delivers primary care. The model calls for nurse practitioners to work alongside dentists, with both seeing the patient at the same time in a specially designed room.

Nurses can take blood pressure and monitor chronic diseases, such as diabetes, while the patient receives dental care. Nurses can also coordinate and schedule cancer screenings or specialist visits.

Sachin Jain, MD, MBA, FACP, the CEO of CareMore, said the idea could help address shortages of primary care physicians. “Dentists know a lot about chronic disease. We just don’t tap that knowledge very much.”

Jain will be part of our Healthcare 2020 Series Panel at the upcoming meeting of the ACO & Emerging Healthcare Delivery Coalition®, which meets May 4-5 in Scottsdale, Arizona.

There’s still time to register.

Patient Preferences in Prostate Cancer

A new study highlights the importance of educating prostate cancer patients about the long-term impact of treatment choices.

The study, appearing in JAMA and funded by the Patient-Centered Outcomes Research Institute, compares sexual dysfunction, incontinence, and other side effects for several treatments, including radical prostatectomy, external beam radiotherapy, and brachytherapy, compared with active surveillance.

Men with radical prostatectomy had the biggest problems with urinary incontinence and sexual dysfunction, while those with external beam radiotherapy reported more bowel problems.

However, the effects plateaued by 24 months, and at that point were not much different from men under active surveillance.

Read the full story.

New Evidence-Based OncologyTM

Alternative payment models are making their way into cancer care, most notably through the Oncology Care Model, a partnership between CMS and commercial payers.

The current issue of Evidence-Based OncologyTM takes a look at issues surrounding new payment models, which are challenging in cancer care where patient needs vary widely.

Check out the issue.

For all of us at the Managed Markets News Network, I’m Laura Joszt. Thanks for joining us.

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