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This Week in Managed Care: February 17, 2017


This week, the top managed care stories included the end of 2 insurance megamergers, a proposed rule to tighten restrictions for the Affordable Care Act, and new legislation in New Jersey provides the nation's strictest mandates for treating addiction.

Two giant managed care mergers are canceled, and the Trump administration moved to limit enrollment under the Affordable Care Act. Welcome to This Week in Managed Care. I’m Laura Joszt.

Insurance Megamergers Break Up

After federal judges put them on hold, 2 giant mergers that would have left the country with just 3 large insurers are now history.

Early Tuesday, Aetna and Humana announced they would cancel their $37 billion merger, which will cost Aetna a $1 billion fee. Hours later, Cigna said it would halt its proposed merger with Anthem, and file suit for $13 billion in damages, in addition to a termination fee of nearly $2 billion.

The Justice Department had argued against both mergers, saying they would harm competition and hurt consumers.

Humana also said it would leave the healthcare exchanges in 2018, because the risk pool remains unbalanced with too many sick people.

While President Donald Trump said this is a sign that “Obamacare continues to fail,” his administration proposed a new rule to limit open enrollment on the exchanges, something insurers have said will help.

Patrick Conway, MD, the acting administrator of CMS, said the rule would protect people in both the individual and small group markets, and help stabilize both.

Said Conway: “Americans participating in the individual health insurance markets deserve as many health insurance options as possible. This proposal will take steps to stabilize the Marketplace, provide more flexibility to states and insurers, and give patients access to more coverage options.”

Instead of a 3-month window, the rule will limit enrollment for 2018 from November 1 to December 15 in 2017. The rule also strengthens screening for eligibility and tightens the use of special enrollment periods, which payers say were abused by those who only bought coverage once they needed care.

NJ's New Opioid Restrictions

New Jersey Governor Chris Christie this week enacted the nation’s strictest mandates for treating opioid and heroin addiction, just over a month after calling for the plan.

New Jersey’s new law, which takes effect in 90 days, will:

  • Require 6 months of treatment, including 28 days when insurers cannot block inpatient care
  • Cap the first opioid prescription at 5 days
  • Require payers to get people into treatment within 24 hours, even if they must go out of network
  • Enact education requirements for all who prescribe opioids

The American Journal of Managed Care spoke recently with Prosecutor Joseph D. Coronato about the opioid crisis in Ocean County, New Jersey, which had 205 deaths from opioids and heroin in 2016.

Prosecutor Coronato spoke about the need to get people into treatment the moment they are ready, especially after they have been saved from an overdose. Watch the interview here.

Home Visits Improve Diabetes Outcomes

A study in the journal Preventing Chronic Disease found that low-income people with diabetes can benefit from working with community health workers in their own homes.

The study examined 145 people who received up to 5 home visits, and compared them with a group that did not get the visits. The study found:

  • Among those with who started with an A1C of 10%, those who received the home visits had greater reductions than those in the control group.
  • The home visit group had more improvements in blood pressure and quality of life, and had fewer visits to the emergency department.

Special Issue on Immuno-Oncology

Finally, Evidence-Based Oncology (EBO) has published its annual issue on advances in immuno-oncology. The third annual issue features updates on advances in CAR-T cells, the need to manage patient expectations, and the importance of having a patient navigator.

EBO Editor-in-Chief Joseph Alvarnas, MD, writes that the progress in immuno-oncology exceeds anything he thought possible at the start of his career in cancer care. “The idea of harnessing the power of the immune system as a means of bringing more effective, better tolerated treatment solutions to patients in need is deeply inspiring.”

For the full issue of EBO, click here.

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

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