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This Week in Managed Care: March 29, 2019


This week, the top managed care news included the Department of Justice siding with a federal judge in striking down the Affordable Care Act; FDA Commissioner Scott Gottlieb, MD, calling for stricter oversight of electronic health records; and a study finding that healthy eating in Medicare and Medicaid is cost effective.

The Justice Department changes course on Obamacare, the outgoing FDA commissioner wants more oversight of electronic health records (EHRs), and a study finds that paying for healthy eating in Medicaid and Medicare makes financial sense. Welcome to This Week in Managed Care, I’m Laura Joszt.

Department of Justice (DOJ) Sides With Federal Judge Striking Down the Affordable Care Act (ACA)

The Trump administration will follow the lead of a federal judge in Texas and call for the entire ACA to be overturned. Monday’s change of position could leave millions without insurance, and reportedly came despite objections from HHS Secretary Alex Azar and Attorney General William Barr, according to Politico.

Reaction from America’s Health Insurance Plans was swift. President and chief executive officer Matt Eyles called it “misguided and wrong,” saying: “This harmful position puts coverage at risk for more than 100 million Americans that rely on it. We will continue to engage on this issue as it continues through the appeals process so we can support and strengthen affordable coverage for every American.”

The change means the DOJ will no longer defend the ACA in court. And that could derail Trump’s efforts to rein in drug prices. Many of the president’s ideas for cutting drug costs would be run from the Center for Medicare and Medicaid Innovation, which was created by the ACA. House Democrats responded Tuesday with a bill that protects patients with pre-existing conditions and creates a national reinsurance program to address those with high-cost catastrophic claims.

Said Congressman Frank Pallone, D-New Jersey, a bill sponsor: “This comprehensive proposal follows through on our commitment to make healthcare more affordable and to defend critical protections for the more than 133 million Americans living with pre-existing conditions.”

For more, visit ajmc.com.

Gottlieb Calls for Stricter Oversight of EHRs

Departing FDA Commissioner Scott Gottlieb, MD, called this week for stricter oversight of EHRs, following a report in Kaiser Health News that found the government has spent $36 billion to convert hospitals and doctors to digital records with mixed results.

Said Gottlieb: “What we really need is a much more tailored approach, so that we have appropriate oversight of EHRs when they’re doing things that could create risk for patients.”

The report found that thousands of deaths, injuries ad near misses are tied to EHRs, and doctors have complained that the systems are not as useful as they should be.

FDA is currently barred from regulating EHRs, but Gottlieb suggested a regulatory path for digital systems that include a patient’s medical history. This would require Congressional action. For more on Commissioner Gottlieb’s final week at FDA, visit ajmc.com.

Incentivizing Health Eating is Cost Effective

A prescription for healthy food can be cost effective if covered by Medicaid or Medicare, a new study has found. Findings in PLoS One Medicine examined 2 scenarios:

  • If 30% of the cost of fruits and vegetables in supermarkets were covered
  • If 30% of the cost of fruits, vegetables, whole grains, nuts, seafood, and plant-based oils were covered

Modeling estimated cardiovascular disease and diabetes that would be prevented, health costs, incremental cost effectiveness, and quality-adjusted life years. Researchers found:

  • The first incentive prevented 1.93 million cardiovascular events, saved $39.7 billion in healthcare costs, with 4.64 million quality-adjusted life years gained.
  • The second incentive prevented 3.28 million cardiovascular events and 120,000 cases of diabetes, created 8.4 million quality-adjusted life years, and saved $100 billion in healthcare costs.

Said co-author Yujin Lee, PhD, postdoctoral fellow, Tufts University, "We found that encouraging people to eat healthy foods in Medicare and Medicaid—healthy food prescriptions—could be as or more cost effective as other common interventions, such as [preventive] drug treatments for hypertension or high cholesterol."

Cancer Guideline Updates Include Germline Testing

Recommendations for germline testing are now part of treatment recommendations in multiple cancer types, following last week’s annual conference of the National Comprehensive Cancer Network in Orlando, Florida. Recommendations in prostate, pancreatic, and ovarian cancer were updated to reflect new studies and approvals that rely on testing for BRCA mutations, among others. Immunotherapy treatment in non-small cell lung cancer should be guided by programmed death ligand-1 (PD-L1) testing.

Said Matthew Gubens, MD, MS, of the University of California at San Francisco Helen Diller Family Comprehensive Cancer Center, “PD-L1 testing is really the name of the game.”

For full coverage of the NCCN meeting, visit ajmc.com.

Academy of Managed Care Pharmacy (AMCP) Coverage

AJMC® was in San Diego this week for the annual meeting of the AMCP. Aimee Tharaldson, PharmD, senior clinical consultant in emerging therapeutics for Express Scripts, offered her overview of the specialty drug marketplace and predicted savings from biosimilars in the next few years, despite the problems these drugs have had reaching the market. She noted that 8 new biosimilars are in the approval pipeline this year.

For full coverage from the AMCP meeting, visit ajmc.com.

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

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