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This Week in Managed Care: June 26, 2020


This week, the top managed care news included CMS proposing rules for value-based contracting in Medicaid; claims data highlighting racial disparities in COVID-19 effects; an interview with Anthony Fauci, MD, on the progress made against HIV.

CMS issues rules to promote value-based contracting and pay for high-cost therapies in Medicaid, Medicare claims data further highlight the COVID-19 pandemic’s toll on racial minorities, and AJMC® speaks with Dr Anthony Fauci on progress made since 1990 in the fight against HIV and AIDS.

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

CMS Issues Rules to Promote Value-Based Contracting, Pay for High-Cost Therapies in Medicaid

Last week, CMS proposed rules to create flexibility for value-based contracting in Medicaid, which officials said would allow the outcomes-based pricing seen in commercial plans to flourish in public plans and, hopefully, give poor patients greater access to the life-changing therapies.

The notice seeks comment on a series of proposals, the most important of which would tackle longstanding barriers to creative pricing instruments, including long-term financing of costly gene therapies, which experts say are needed if low-income patients are to have equal access to the most innovative treatments.

The proposal also calls for establishing minimum standards in Medicaid’s state drug utilization review, which is designed to reduce opioid-related fraud and abuse.

“CMS’s rules for ensuring that Medicaid receives the lowest price available for prescription drugs have not been updated in 30 years and are blocking the opportunity for markets to create innovative payment models,” said CMS Administrator Seema Verma in a statement. “By modernizing our rules, we are creating opportunities for drug manufacturers to have skin in the game through payment arrangements that challenge them to put their money where their mouth is.”

For more, visit ajmc.com.

Medicare Claims Data Further Highlight Pandemic’s Toll on Racial Minorities

This week, CMS released preliminary data indicating that black Americans with Medicare coverage are nearly 4 times more likely than white Americans to be hospitalized for COVID-19, with Hispanics also found to be 2 times more likely than their white counterparts.

In response to the figures, the Trump administration issued a call to action for a “renewed national commitment to value-based care.” Currently, the Center for Medicaid and Children’s Health Insurance Program Services is developing guidance for states to implement value-based payment design and strategies to address social determinants of health.

Notably, the CMS Office of Minority Health, or OMH, will be holding a series of listening sessions with stakeholders responsible for providing care to racial and ethnic minorities, which are “intended to help refine the ongoing outreach and work by CMS to improve future efforts on this issue.”

This follows an announcement by HHS of a $40-million partnership between OMH and the Morehouse School of Medicine to fight COVID-19 in racial and ethnic minority and vulnerable communities.

For more, visit ajmc.com.

What Is Being Done to Assess the Disproportionate Effect of COVID-19 on Minority, Rural Communities?

Racial disparities in COVID-19 were the focus of a video interview conducted last week with Dr Gloria Wilder, vice president of Innovation and Health Transformation at Centene, and Dr Gary Puckrein, president and chief executive officer of the National Minority Quality Forum, or NMQF.

Centene and the NMQF announced a research partnership for the Minority and Rural Health Coronavirus Study to assess the impact of COVID-19 on minority and underserved communities across the country.

In addition to increased hospitalizations due to COVID-19, black Americans were also noted in the interview to be at a 3 times greater risk of death.

While some may attribute this increased mortality rate to comorbidities such as diabetes and hypertension, which disproportionately affect African Americans, Wilder highlights that even after controlling for chronic illness, statistics still expose significant health disparities.

For the full interview, visit ajmc.com.

Fauci: Countless Lives Have Been Saved, but an HIV Vaccine and Cure Remain Elusive

To mark the 25th anniversary of The American Journal of Managed Care®, we spoke with the nation’s top infectious disease expert, Dr Anthony Fauci, on progress that has been made in the fight against HIV and AIDS.

Fauci, who is director of the National Institute of Allergy and Infectious Diseases and has been with the organization for 36 years, has an extensive history in the fight against the virus. Notably, Fauci gave a keynote address at the 6th International AIDS Conference in San Francisco in 1990.

Fauci spoke on a wide array of topics related to HIV and AIDS, including treatment with AZT and Truvada; undetectable viral loads; why there is no cure just yet; and how the first tumultuous years of the AIDS crisis shaped research for decades to come.

For the full interview, visit ajmc.com.

PwC Provides 3 Spending Scenarios to Address Implications of COVID-19 on the 2021 Medical Cost Trend

This week, PwC’s Health Research Institute, or HRI, released its annual report, “Medical Cost Trend: Behind the Numbers 2021,” which helps guide employers and payers as they determine health plan premiums for the coming year.

In an interview with AJMC®, Ben Isgur, HRI leader at PwC, spoke on how the COVID-19 pandemic affected last year’s projections and how they have been implemented into this year’s report.

To address the uncertainty of the pandemic and the emergence of services such as behavioral health and telehealth, Isgur and colleagues provided 3 different spending scenarios for employers managing the insurance market, categorized as low, medium, and high.

Based on these factors, researchers expect a 4% to 10% increase in the medical cost trend for 2021.

For the full interview, 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.

Amid innovations within HIV treatment and care, this week’s 1998 paper spotlighted how the prevalence of comorbidities such as anemia and syphilis impacted delivery of care for out-of-treatment drug users.

Analyzing data derived from a managed care model, researcher Dr Isaac D. Montoya found that a high rate of male and female drug users with HIV had syphilis and anemia. These findings highlighted that adherence to drugs is not the sole issue to address in patients with comorbidities also serving as vital factors in designing managed care plans.

For the paper, visit ajmc.com.

For all of us at AJMC®, I’m Matthew Gavidia.

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