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This Week in Managed Care: April 27, 2018


This week, the top managed care stories included an announcement from CMS of creating direct provider contracting, plus a broad set of proposed rules for health information technology; new recommendations to improve postpartum care; a look at future competition among specialty drugs.

CMS may test paying providers directly, hospitals must share more information about pricing, and a report calls for doctors to see new mothers more frequently.

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

Direct Provider Contracting

Citing the need to ease administrative burdens, CMS this week asked for comments on “direct provider contracting,” which would pay providers a fixed amount for each beneficiary per month as well as performance incentives, while offering flexibility in billing other services.

The change would seek to increase accountability and move more providers to take on 2-sided risk by cutting out middlemen.

But some consumer groups and advocates for seniors were wary that this could encourage physicians to create classes of Medicare beneficiaries. Said AARP: “Medicare’s rules for balance billing and private contracting are important financial protections for Medicare beneficiaries. … Without Medicare’s consumer protections, Medicare beneficiaries would face higher out-of-pocket costs from balance billing and private contracts.”

Control of Health Plan Information

CMS took additional steps this week to give patients more control over their health plan information and to require hospitals to disclose prices. A broad set of proposed rules announced Tuesday also calls for providers to start using 2015 electronic health record technology by next year and weeds out duplicative quality measures.

Said CMS Administrator Seema Verma, “We seek to ensure the healthcare system puts patients first. [The] proposed rule demonstrates our commitment to patient access to high-quality care while removing outdated and redundant regulations on providers.”

Finally, CMS plans to update the way it reimburses CAR T-cell therapy to include technology add-on payments, reflecting the complexity associated with this novel treatment for certain leukemias and lymphomas.

Improving Maternity and Postpartum Care

Rising deaths among new mothers in the United States received attention this week. First, Humana announced a new value-based maternity bundled payment model that will start with 5 practices in Kansas, Ohio, Texas, and Indiana.

And, the American College of Obstetricians and Gynecologists, cited the need to reduce severe mortality and morbidity among new mothers in a new report that called for more frequent doctors’ visits.

All women need a visit with their obstetrician within 3 weeks after giving birth and should have a comprehensive follow-up visit within 12 weeks, according to ACOG.

Among the recommendations:

  • Postpartum care should be an ongoing process, not a single encounter
  • Timing of future pregnancies and contraception should be part of the discussion
  • Postpartum care must assess a woman’s physical, social, and psychological well-being
  • Women with chronic conditions, such as hypertension, diabetes, or mood disorders, need counseling on timely follow-up for ongoing care

AJMC will bring you full coverage of the ACOG annual meeting this weekend from Austin, Texas. To register for our conference coverage, visit ajmc.com.

Specialty Drug Pipeline

Competition on the specialty drug market could heat up in the next several years as therapies come off patent, creating new opportunities, especially in biosimilars. That’s what one expert shared with a capacity audience this week at the Academy of Managed Care Pharmacy (AMCP) annual meeting in Boston, Massachusetts.

Aimee Tharaldson, PharmD, of Express Scripts, said maturing specialty classes in HIV, multiple sclerosis, and psoriasis will create a $25 billion market opportunity as 64 drugs come off patent protection.

Similar opportunities exist in biosimilars, with 10 awaiting approval this year to treat:

  • Anemia
  • Breast cancer
  • Neutropenia
  • Rheumatoid arthritis
  • Non-Hodgkin lymphoma
  • Chronic lymphocytic leukemia
  • Psoriasis

Tharaldson said FDA’s efforts to increase competition will eventually bring significant savings, but it’s taking longer than everyone would like.

Check out our full coverage of AMCP.

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

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