This Week in Managed Care: August 6, 2016

This week, the top stories in managed care included penalties for more than half the nation's hospitals for readmissions, CMS announced the markets to participate in Comprehensive Primary Care Plus, and Express Scripts released its formulary for 2017, which excluded 85 of the 3900 drugs on the market.

Hello, I’m Justin Gallagher, associate publisher of The American Journal of Managed Care. Welcome to This Week in Managed Care, from the Managed Markets News Network.

Readmission Penalties

Medicare will withhold more than half a billion dollars in the next year due to hospital readmissions. This week, Kaiser Health News reported that more than half of the nation’s hospitals had more patients than expected return within 30 days of being discharged.

Hospitals will lose $528 million in penalties, an increase of $108 million from last year’s total. The increase follows a change in the way readmissions are measured.

Primary Care Model Expansion

This week, CMS announced 14 statewide and regional markets where primary care physicians can apply to take part in Comprehensive Primary Care Plus, an expansion of a care delivery model that has been tested in 500 practices across the country over the past four years.

The new model, called CPC-plus, will reach 5000 practices and 3.5 million patients starting in 2017. CMS has set up a series of new payment methods designed to reward doctors for care coordination, patient engagement, and preventive care.

Practices can receive flat fees for care management on a sliding scale, depending on the patient’s level of risk. While the smaller pilot produced mixed results, at least one payer is looking forward to participating.

Said Allen Karp, senior vice president for Healthcare Management of Horizon Blue Cross Blue Shield of New Jersey, “CPC+ will help infuse millions more in payer dollars so that additional practices can bring this improved care delivery approach to their patients.”

Express Scripts Formular Exclusions

The pharmacy benefit manager Express Scripts released its 2017 National Preferred Formulary, which excludes 85 of the estimated 3900 drugs on the market. Therapies on the exclusion list include the hepatitis C treatment Sovaldi and several newer therapies for diabetes and obesity.

One of the diabetes drugs, the GLP-1 inhibitor liraglutide, was excluded despite recent results that show it provides a cardioprotective benefit, unlike its competitors. Novo Nordisk, the maker of Victoza, the brand name for the liraglutide formulation used in diabetes care, declined to say whether Express Scripts’ decision is a bad sign for its proposed combination therapy, Xultophy, which combines liraglutide and insulin. An FDA approval decision on Xultophy is expected in September.

Said Novo Nordisk’s Michael Bachner, “At this time, we cannot comment on the formulary coverage for Xultophy. Novo Nordisk is committed to ensuring that Xultophy is accessible and affordable for all appropriate patients.”

ACO Coalition Fall 2016

Mark McClellan, who served as both FDA Commissioner and Administrator of CMS under President George W. Bush, will be the keynote speaker at the fall meeting of the ACO and Emerging Healthcare Delivery Coalition, scheduled for October 20-21 in Philadelphia. McClellan, who is now the director of the Duke-Margolis Center for Health Policy, will speak on “Reforming Medicare.”

For information and to register, visit the conference page.

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