This Week in Managed Care: July 19, 2019

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This week, the top managed care news included CMS pushing for bundled payments in radiation oncology; reports detailing deficiencies in hospice care; a study finding widening disparities in life expectancy among white Americans.


CMS proposes a new way to pay for radiation oncology, federal watchdogs find deficiencies in hospice care, and a new study finds widening disparities in life expectancy among white Americans.

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

CMS Pushes for Bundled Payments in Radiation Oncology

The Trump administration wants to bring bundled payments to radiation oncology, a potential money-saving move that would cover 17 types of cancer and be mandatory in some parts of the country. The Radiation Oncolocgy Model would make bundled payments to:

  • Physician group practices
  • Hospital outpatient departments
  • Freestanding radiation centers

CMS will require participation in areas to study whether site-neutral, episode-based payments reduce Medicare costs while improving quality of care. The model will qualify as an advanced alternative payment model under the Medicare Access and CHIP Reauthorization Act of 2015. Payments would be split into 2 parts: a professional component for physician services, and a technical component for equipment, supplies, and other costs.

CMS cited 3 reasons why radiation oncology needs payment reform:

  • Lack of site neutrality for payments
  • Incentives that encourage volume over value
  • Coding and payment challenges

The Community Oncology Alliance said it had deep reservations about the plan, and fundamental opposition to a mandatory or required model.

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Deficiencies in Hospice Care

Most hospices in the United States have at least 1 deficiency, and patients have been harmed as a result of poor care or cases of abuse. Those were the findings in 2 reports from the HHS Office of the Inspector General (OIG). The first report covered deficiencies from 2012 to 2016 and found that 80% of hospices serving Medicare beneficiaries had at least 1 deficiency over the full 5 years. The share of hospices with a deficiency peaked at 76% in 2015.

Common deficiencies include:

  • Poor care planning
  • Mismanagement of aide services
  • Inadequate assessment of beneficiaries

The second report covers 12 cases of harm and pinpoints vulnerabilities that led to the harm, with a roadmap for avoiding these incidents. These included:

  • Failing to provide essential pain management
  • Not providing care for a person vomiting blood
  • Failing to recognize signs of a possible sexual assault

The OIG recommended 5 safeguards, which included stronger reporting requirements, better staff education, and empowering patients and caregivers to make complaints.

The report concluded: “The findings make clear the need for CMS to strengthen its oversight of the Medicare hospice program to better protect both the program and its beneficiaries.”

Declining Life Expectancy Among White Americans

A new study has found geographic divisions behind the declining life expectancy among white Americans. The study, led by researchers at the University of Pennsylvania, found that rising white mortality has connections to education and access to healthcare, but it’s hard to pinpoint a single exact cause.

Among the notable findings:

  • Obesity stands out as a defining feature in counties with rising mortality among white Americans
  • While access to healthcare appears to aid life expectancy, direct cash welfare does not
  • The opioid crisis has played a major role in rising mortality, as deaths from overdoses have climbed while the health system has made progress in cancer and cardiovascular disease

But the most important findings, which confirm CDC reports of falling life expectancy, are that the mortality gap is getting wider between metropolitan and rural areas.

Said study co-author Samuel Preston, PhD, professor of Sociology at the University of Pennsylvania: “The biggest contrast we saw was between large metropolitan areas and their suburbs and non-metropolitan areas, which have moved in different directions. Between 1990 and 2016, non-metropolitan areas had rising mortality, which is extremely unusual in the context of life expectancy that has gotten better nearly every year for nearly every group for more than a century.”

Both Systolic and Diastolic Blood Pressure Predict Cardiovascular Events

A study published this week finds that increases in a person’s systolic blood pressure (BP) have a greater effect on outcomes than rising diastolic BP. But both readings independently assess the risk of heart attacks or strokes, according to new study appearing in the New England Journal of Medicine.

Investigators from the Kaiser Permanente Research Division reached this conclusion after examining data from 1.3 million patients covering an 8-year period, and noted that the results held up whether they used the old high BP guidelines or the new ones adopted in 2017 by the American Heart Association and the American College of Cardiology.

The guidelines said high BP begins when systolic BP reaches 130 and diastolic BP reaches 80, instead of 140 over 90. Researchers said their findings support the decision to reduce the threshold for high BP among high risk patients.

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Number of Manufacturers and Generic Drug Pricing

Finally, the new issue of The American Journal of Managed Care® features a study that highlights the frustration over rising drug prices. If you thought that using generic drugs was a sure way to avoid high drug costs, think again. Researchers from the University of Pittsburgh School of Pharmacy and its medical center, led by Inmaculada Hernandez, PharmD, PhD, found that prices for generic drugs rose sharply after 2010, even if they were supplied by more than one manufarturer.

In fact, the share of drug prices supplied by 1 to 3 manufacturers that doubled in price in a year was more than 3 times higher from 2012 to 2015 than it was from 2005 to 2009.

The authors wrote: "Our results signal market failures in the generic drug market and warrant the consideration of policy strategies to increase the sensitivity of generic drug prices to competition."

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