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This Week in Managed Care: July 30, 2016


This week, the top stories in managed care included the release of Medicare's Star ratings for hospital quality, a new proposal from CMS to require bundled payments for cardiac care, and an FDA panel recommended approving a continuous glucose monitoring system for dosing insulin.

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.

Bundled Payments for Cardiac Care

Treatment for heart attacks and bypass surgery could be the next area where Medicare requires bundled payments. CMS proposed a plan this week to require hospitals in 98 markets to use a bundled payment model starting in July 2017.

Bundled payments, which give hospitals a flat fee for all care associated with an episode, are already required for hip and knee replacements in 67 markets, and this week’s proposal would also expand that program.

The American Hospital Association expressed concern that CMS is demanding too much change at once. Said AHA Executive Vice President Tom Nickels, “The proposal to bundle payments in cardiac care is the third mandatory demonstration project from CMS in a little over a year … CMS also is proposing to expand and further complicate the hip and knee program less than four months after it began. CMS is putting the success of these critical programs at risk.”

Hospital Star Ratings

The AHA was among the groups that questioned CMS’ other big news this week—the release of hospital ratings under the Medicare Stars program. Stakeholders and members of Congress had asked whether the ratings should come out when there are many questions about whether they are fair to safety net hospitals.

Overall data show that safety-net and teaching hospitals are more likely to receive below-average ratings in the Stars program, and critics say CMS does not properly weigh how patient poverty affects the results.

Read more about the Star ratings controversy.

Breakthrough for Melanoma Therapy

Daratumumab, sold as Darzalex, received its second breakthrough status designation this week. The therapy gained recognition as a second-line treatment with standard of care for multiple myeloma patients who have had at least one therapy.

FDA acted based on results from two phase 3 trials, which found daratumumab reduced both the risk of disease progression and death.

CGM Coverage

Medicare beneficiaries who have diabetes are one step closer to getting coverage for continuous glucose monitoring (CGM), following a landmark meeting of an FDA panel last week. The group recommended a new indication for Dexcom’s G5 Mobile system, which would allow patients to use CGM when deciding how much insulin to take.

Until now, FDA labeling required that patients do a blood test prior to all treatment decisions, even though many type 1 patients use their CGM for dosing. If approved by FDA, the new indication could pave the way for Medicare coverage, since CGM would be replacing needlesticks in many cases.

For our coverage of the FDA meeting, read AJMC's article.

Kolodziej Joins Flatiron Health

Dr Michael Kolodziej, who is a frequent contributor to AJMC and a participant in our annual meeting, Patient-Centered Oncology Care, will join Flatiron Health as its National Medical Director for Managed Care Strategy.

Kolodziej, a longtime practicing oncologist, has been the national medical director for oncology strategy at Aetna for more than 3 years. Kolodziej recently discussed the need to find common ground during our Oncology Stakeholders’ Summit. Watch the video.

We look forward to working with Dr. Kolodziej in his new role at Flatiron Health.

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

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