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This Week in Managed Care: August 31, 2018


This week, the top managed care stories included encouraging results from the Next Generation Accountable Care Organization model; concerns that CMS' new billing rules will hurt the sickest patients; a study confirms the value of daily aspirin for patients with diabetes.

CMS sees encouraging results from a new ACO model, aome say new billing rules will hurt the sickest patients, and a study confirms the value of daily aspirin for patients with diabetes.

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

Success With Next Gen ACOs

The Next Generation Accountable Care Organization, a 2-sided Medicare risk model that started in 2016, generated $62 million in savings across 18 health systems during its first year. CMS announced the savings this week and said most of the savings came from reductions in hospital and skilled nursing spending.

Said CMS Administrator Seema Verma, “The more risk a provider is willing to take, the more flexible CMS wants to be. We recognize that sometimes regulations are standing in the way of delivering good quality care. … To the extent that providers are taking on risk, it gives us the ability to be flexible in a lot of different ways, whether its program integrity or beneficiary engagement.”

Verma said the next step of the movement toward value-based care must do more to involve patients.

Concerns With New Billing Rules

However, provider groups led by the American Medical Association said this week that proposed changes to Medicare physician payment rules could be harmful to the sickest patients.

A plan to streamline a set of billing codes, called evaluation and management, would remove differences based on the complexity of a patient’s case. If providers are paid the same regardless how sick a patient is, some fear that doctors who care for the sickest patients will be penalized.

The American College of Rheumatology was among the specialties that wrote CMS and said time-intensive services like care coordination and risk assessment are already under compensated.

Read more.

Value of Daily Aspirin

Serious vascular events in patients can be avoided with daily aspirin use, according to results presented this week.

Findings from the ASCEND study, presented at the European Society of Cardiology in Munich, Germany, compared adults with diabetes who took 100 milligrams of aspirin with those taking placebo. No one in the trial had cardiovascular disease.

After 7 and a half years, only 8.5% of the patients taking aspirin were treated for vascular events, compared with 9.6% of those taking placebo. However, patients taking aspirin were at greater risk for bleeding.

Said Jane Armitage, FRCP, FFPH, of the University of Oxford, “Even though we showed clearly that aspirin reduces the risk of vascular events, including heart attacks, strokes, and mini-strokes, it also increased the risk of major bleeds, from the gastrointestinal tract, so overall there was no clear benefit.”

Drug Price Transparency

The Senate has passed a bipartisan amendment that would give HHS $1 million to develop regulations on direct-to-consumer advertising. The new rules would require drug makers to include product prices in ads.

The amendment, attached to a spending bill, would fulfill an item in President Trump’s blueprint to rein in prescription drug pricing.

The Kaiser Family Foundation found in a June 2018 poll that 76% of Americans across the ideological spectrum favor a federal requirement for drug advertisements to include information about how much a drug costs.

Read more.

Lingering Affects of Sequester

Finally, authors writing on behalf of the Community Oncology Alliance have found that community oncology practices have lost $78 million due to the federal sequester, an automatic cut to government spending that came when Congress and the administration were unable to reach a balanced budget in 2011. The sequester affects reimbursement for Part B drugs in Medicare to this day.

Lucio Gordan, MD, Cass Schaedig and Susan Weidner analyzed claims from community practices by size and evaluated the percentage loss relative to the drug-related operating margin. The study found:

  • At the start of 2016, each practice lost 28% to 31% due to sequestration
  • Small and medium practices were hit harder in 2017, with losses of 38.4% and 34.7%
  • The average loss is 32% in the first quarter of 2018

Said Gordan, “This research quantifies what we have known for far too long: The sequester cut has decimated the community oncology system, causing millions of Americans to lose access to high-quality, affordable cancer care close to where they live and work.”

Read the full study, which will appear in the October issue of Evidence-Based Oncology.

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

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