This Week in Managed Care: August 10, 2018

Published on: 

This week, the top managed care stories included, CMS allowing step therapy in Medicare Advantage plans in a bid to allow for drug price negotiation; larger practices with more resources, technology and care management processes have higher readmission rates than smaller practices; studies find that empagliflozin also reduces liver fat in patients with diabetes and nonalcoholic fatty liver disease.


CMS will allow step therapy in Medicare Advantage, new add-on payments will help cover the cost of CAR T-cell therapy, and a study finds larger practices have higher readmission rates.

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

Step Therapy in Medicare Advantage Plans

CMS announced this week it will allow Medicare Advantage plans to use step therapy to negotiate prices for Part B drugs, such as chemotherapy given at a physician’s office.

CMS Administrator Seema Verma told reporters that this new tool could lower costs for seniors by letting them try lower-cost drugs or biosimilars before moving to more expensive therapies.

But leaders of the Community Oncology Alliance said this “fail first” approach could be dangerous to seniors with cancer.

Said COA President Jeff Vacirca, MD, FACP of New York Cancer Specialists, “Cancer treatment is becoming more personalized and not all therapies produce the identical result from patient to patient. Having therapy options is imperative to successful treatment. CMS’ action is the antithesis to where personalized medicine is going—it’s old school, cookbook medicine that treats every patient as one size fits all.”

Extra Payments for CAR T-Cell Therapies

The change came days after CMS announced how it will pay for chimeric antigen receptor (CAR) T-cell therapy in the near term.

As it finalizes a series of rule changes for 2019, the agency said it will use technology add-on payments to help cover the cost of this personalized gene therapy, paying up to 186,500 dollars per case. Institutions will use this alongside Medicare’s bone marrow transplant diagnosis code, which reimburses at a high rate.

Today, FDA has approved 2 CAR T-cell therapies, Kymriah and Yescarta, in limited cases of leukemia and lymphoma when other treatments have failed. But research in the pipeline suggests many new approved uses are on the way.

CMS is exploring a new payment model for CAR T-cell therapy and is conducting a national coverage analysis. A hearing on patient-reported outcomes is set for August 22.

Read more.

Practice Size and Readmission Rates

With more resources, technology, and care management processes, large practices are thought to be more capable of preventing hospital readmissions. But that’s not always true, according to new research.

Claims data from the third National Study of Physician Organizations and Medicare shows that practices of under 10 physicians cared for more patients who were also enrolled in Medicaid and had disabilities but spent less and had lower readmission rates on these frail patients than the large practices.

The authors wrote: “Surprisingly, practices that used more [quality improvement], [health information technology], and [systematic care management processes] did not have lower spending or higher quality, even for the highest need beneficiaries, who might benefit the most.”

Predicting Who Will Benefit From Immunotherapy

A liquid biopsy that tells doctors which patients with non—small cell lung cancer will benefit from checkpoint inhibitors may soon be on the way. A study published in Nature Medicine established a tumor mutational burden in blood that correlates well with similar levels in tissue.

The discovery could ultimately save time and money in testing, because patients sometimes do not have enough tissue to perform all the necessary tests, and blood tests are less invasive.

Foundation Medicine, which conducted the study with Genentech and UC Davis, will now seek FDA approval for the liquid biopsy.

Diabetes and Fatty Liver Disease

Finally, recent studies suggest that the SGLT2 inhibitor empagliflozin could be the first choice instead of metformin for patients with nonalcoholic fatty liver disease, which affects between 50% and 70% of people with diabetes.

Mohammad Shafi Kuchay, MBBS, MD who published the E-LIFT study in Diabetes Care, told The American Journal of Managed Care® this week that other data published in Diabetologia support his findings that patients with type 2 diabetes and fatty liver disease saw a measurable reduction in liver fat after taking empagliflozin for 20 weeks.

Said Kuchay: “Finding effective treatment for reducing liver fat and preventing or treating [nonalcoholic fatty liver disease] is an urgent global public health need. There is no medicine approved for NAFLD at present. Empagliflozin has a high potential of getting approval for NAFLD in patients who also have type 2 diabetes.”

To learn more about nonalcoholic fatty liver disease and its more severe form, nonalcoholic steatohepatitis, or NASH, listen to this week’s Managed Care Cast, where we hear from a clinician and a patient advocate.

For all of us at The Managed Markets News Network, I’m Laura Joszt.