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This Week in Managed Care: August 7, 2020


This week, the top managed care news included CMS updates on telehealth and more; COVID-19 vaccine developments and remaining challenges; a study examines the impact of state policies on life expectancy.

CMS releases updates on evaluation and management services, telehealth, and accountable care organizations; experts highlight COVID-19 vaccine developments and remaining challenges; and a study examines how state policies may impact life expectancy.

Welcome to This Week in Managed Care, I’m Matthew Gavidia.

CMS Releases E&M Updates, Expands Telehealth, Makes ACO Changes

Among a swath of proposed policy and payment changes announced this week by the Trump administration, CMS continued its effort to simplify coding requirements, quality measurements, and focus on 340B drug costs.

This past Tuesday, CMS released the proposed calendar year 2021 Physician Fee Schedule, which includes Quality Payment Program changes affecting accountable care organizations and how evaluation and management, or E&M, services are billed, such as examinations, disease diagnosis, risk assessment, and care coordination.

Explaining some of the raft of changes Tuesday, CMS Administrator Seema Verma said E&M codes have not been updated in 2 decades and do not reflect the growing number of chronic conditions and medically complex patients or social determinants of health.

“The value of E&M has decreased as complexity has increased,” said Verma.

In the 340B drug program, CMS would, in 2021, cut the payment rate for drugs to the average sales price minus 28.7%.

CMS said the change would save Medicare beneficiaries an additional $85 million in out-of-pocket payments for these drugs and that the savings would be reallocated among all hospitals on an equal percentage basis, while exempting certain cancer hospitals, rural sole community hospitals, and children’s hospitals.

For more, visit ajmc.com.

Experts Highlight COVID-19 Vaccine Developments and Remaining Challenges

Of the more than 160 COVID-19 vaccine candidates being examined in clinical trials, those that are leading the pack are utilizing a new vaccine technology that has never been approved for human use by the FDA, which has contributed to significant unknowns.

In a free, 1-hour webinar from MJH Life Sciences™, the parent company of The American Journal of Managed Care®, 3 top experts discussed vaccine development, the latest clinical trial evidence, and the future of COVID-19 vaccines.

Missed the webinar? You can still register for free and watch the video on demand!

For more coverage of the webinar and to register, visit ajmc.com.

How Do State Policies Impact Life Expectancy?

Published this week in The Milbank Quarterly, a study found that since 1970, changes in US state policies have played an important role in the stagnation and recent decline in life expectancy, while some policies appear to be key levers for improving life expectancy.

In 2016, life expectancy of American women was 3 years below the female average of high-income countries and 5.8 years below the leading country for life expectancy, with US men also having shorter life expectancies at 3.4 years below the average and 5.2 years below the leader.

When it comes to root causes of these disparities, one major contributor is a rise in so-called “deaths of despair,” or deaths due to suicide or drug and alcohol abuse. Different regional policies on firearm use and availability of substance abuse rehabilitation programs can alter expectancy gains or declines across state lines.

Local policies were found to affect nearly every aspect of an individual’s life including economic well-being, social relationships, education, housing, lifestyles, and access to medical care, authors point out.

If the status quo is maintained, thereby allowing the current policy direction of states to continue, researchers found the results would yield minimal improvements in longevity. However, authors caution the analyses do not prove state policies have a causal effect on life expectancies.

“Taking these findings together, the slow gains in US longevity may partly reflect the national shift toward some conservative policies that are negatively associated with longevity, such as abortion restrictions, reductions in gun control,” researchers conclude.

For more, visit ajmc.com.

Tafasitamab Combination Approved for Adults With R/R DLBCL

Last Friday, the FDA approved tafasitamab to be used in combination with lenalidomide for second-line treatment of adult patients with relapsed or refractory diffuse large B-cell lymphoma, or DLBCL, meeting the needs of patients who are not eligible for an autologous stem cell transplant.

Approval was based on phase 2 results for 80 patients in the L-MIND trial, which reported an update May 2019 at the American Society of Clinical Oncology, with final results published last month in The Lancet. Results submitted to the FDA showed an overall response rate of 55%, including a compete response rate of 37% and a partial response rate of 18%.

Among non-Hodgkin lymphomas, DLBCL is the most common subtype, accounting for 22% of cases in the United States and 40% worldwide, with about 18,000 US cases per year. Tafasitamab, to be sold as Monjuvi by MorphoSys and Incyte, is a humanized Fc-modified cytolytic CD19 monoclonal antibody being studied in several B-cell malignancies.

“The FDA approval of Monjuvi in combination with lenalidomide helps address an urgent unmet medical need for patients with relapsed or refractory DLBCL in the United States,” said Hervé Hoppenot, CEO of Incyte, in a statement.

For more, visit ajmc.com.

Paper of the Week

And, now our Paper of the Week, which looks back at some of the most important papers over the past 25 years of The American Journal of Managed Care® and why they matter today.

News about updates in E&M codes brings us back to an important 2014 paper from Dr. Richard Young and Tiffany Overton, whose review of data showed that billing codes did not fully reflect the scope of work done by family physicians, and contributed significantly to income disparities between these critical clinicians and specialists.

The disconnect between billing codes and actual work performed revealed a gap not only in income but in the way the physicians’ work is valued.

For more, visit ajmc.com.

For all of us at AJMC®, I’m Matthew Gavidia. Thanks for joining us!

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