This Week in Managed Care: March 31, 2017

This week, the top managed care news included new radiology guidelines for early-stage breast cancer; 4 continuing healthcare challenges for President Donald Trump; and Medicare coverage for Dexcom's continuous glucose monitor.

Radiologists have new guidelines for treating breast cancer, health plans brace for 2 expensive new drugs, and the issue of healthcare isn’t going away for President Trump.

Welcome to This Week in Managed Care, I’m Brielle Urciuoli.

New Breast Cancer Guidelines

Radiologists treating women with breast cancer have new guidelines following the annual conference of the National Comprehensive Cancer Network, which met last week in Orlando, Florida. The guidelines, updated this month, are designed to tailor radiation doses to individual patients and spare surrounding tissue.

Kilian Salerno, MD, of the Roswell Park Cancer Institute said understanding the target area is the key to giving patients the best treatment. “The target region to receive the radiation dose can vary. It might be the whole breast; the partial breast, where we may target the lumpectomy cavity; the chest wall; or just regional nodes.”

See coverage from the NCCN annual conference.

New Drug Approvals

New biologics to treat progressive multiple sclerosis and atopic dermatitis were on the radar this week at the Academy of Managed Care Pharmacy annual meeting in Denver, Colorado.

Ocrevus, to treat MS, and Dupixent, for atopic dermatitis, were approved both Tuesday, with Dupixent priced at 37 thousand dollars a year.

Aimee Tharaldson, PharmD, of Express Scripts, told AJMC that Dupixent is a very effective drug and that it should reach the market quickly. Watch the interview.

For more from the AMCP annual meeting, visit the conference page.

Healthcare Agenda

House Republicans may have shelved their plan to repeal and replace the Affordable Care Act, but that doesn’t mean healthcare isn’t still an issue for President Donald Trump.

With health plans now facing June deadlines to submit rates for 2018, the Trump administration has at least 4 immediate healthcare challenges:

  • Republicans must decide whether to fund cost-sharing subsidies
  • Conservative states like Kansas may expand Medicaid
  • Multiple health plans are suing to recover funds for risk corridors, and
  • Investigators are asking whether the Trump team acted appropriately in January when it stalled the ad campaign for open enrollment.

Meanwhile, reports suggest Trump will try again soon to reach an agreement on replacing the ACA.

CGM Coverage

Medicare patients who need insulin to treat their diabetes received good news this week: CMS has published rules on how they can get coverage for the Dexcom G-5 continuous glucose monitor, which received an FDA approval for patients to use for insulin dosing.

Diabetes advocates have worked for years for this rule change, but there’s a catch: Medicare won’t pay for the CGM systems if patients use their smartphones to monitor their blood glucose data. According to the approval, patients cannot even use their smartphones alongside the data receiver that comes with the system, because smartphones are not “durable medical equipment.”

Debra Parrish, an attorney who has represented diabetes patients in Medicare appeals, called this decision “nonsensical.”

“Durable medical equipment does not become non-durable if Medicare beneficiary uses a smartphone app with the device. This novel restriction appears to be designed to ensure that the only CGM that is covered by Medicare will not be covered for those individuals who use it to its full functionality to monitor their glucose levels.”

Avik Roy at ACO in Scottsdale

Healthcare commentator Avik Roy will lead an all-star lineup at spring meeting of the ACO and Emerging Healthcare Delivery Coalition, which AJMC will bring to Scottsdale, Arizona, May 4-5. Roy is a leading conservative advocate for universal healthcare and the opinion editor at Forbes.

The spring meeting theme, Prepare for Impact, will help healthcare leaders get ready for changes coming in the Trump Administration. For information and to register, click here.

For everyone at the Managed Markets News Network, I’m Brielle Urciuoli.

Thanks for joining us.