This Week in Managed Care: May 1, 2020

The Supreme Court says insurers are owed $12 billion under the Affordable Care Act; a study finds those with cancer are at higher risk from coronavirus disease 2019 (COVID-19); a survey shows millions would avoid seeking care for COVID-19 due to cost.

The Supreme Court says insurers are owed $12 billion under the ACA, a study finds those with cancer are at higher risk from COVID-19, and a survey shows millions would avoid seeking care for COVID-19 due to cost.

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

Supreme Court: Government Owes ACA Insurers $12 Billion

This week, the Supreme Court found that health insurers that took on the risk of covering millions of previously uninsured Americans must be millions they are owed under the Affordable Care Act.

In an 8 to 1 ruling, the justices said insurers were owed payments due from 2014 to 2016, when they were to be reimbursed for some losses during the first years of enrollment on the exchanges.

After Republicans gained control of Congress in 2015, the blocked HHS from using monies outside the risk corridor program to pay insurers $12 billion owed under the ACA formula.

The statute “set a formula for calculating payments under the program: If an insurance plan loses a certain amount of money, the Federal Government ‘shall pay’ the plan; if the plan makes a certain amount of money, the plan ‘shall pay’ the Government,” according to the court’s opinion, issued by Justice Sonia Sotomayor.

For more, visit

COVID-19 Increases Overall Risk of Death, Complications in Patients With Cancer

Patients with cancer who become infected with COVID-19 are far more likely to die or suffer severe complications than patients with COVID-19 who do not have cancer, a new study has found.

Findings presented at the virtual meeting of the American Association of Cancer Research, or AACR, show that patients with cancer who develop COVID-19 were more likely to develop in-hospital infections or chest distress or spend time in the intensive care unit.

Patients being treated with immunotherapy appearing to be at particularly high risk.

The pandemic has left in its wake forced treatment delays, shuttered clinical trials, and decimated pain medication supplies, notes Dr. Howard A. “Skip” Burris, chief medical officer and executive director of the Sarah Cannon Research Institute and president of the American Society of Clinical Oncology.

Burris called these challenges “daunting,” because they can be “devastating for patients with fast-moving or hard-to-treat cancers.”

For more, visit

Phase 3 EMBRACA Findings Suggest No Overall Survival Benefit With Talazoparib in Advanced BRCA-Mutated Breast Cancer

Other results presented at AACR include new data from the phase 3 EMBRACA trial.

Researchers found that PARP inhibitor talazoparib showed no statistically significant benefit in the secondary end point of overall survival in patients with metastatic HER2-negative breast cancer and mutations in the BRCA 1 and 2 genes.

In the trial, nearly half of patients in the talazoparib group received another PARP inhibitor or platinum therapy compared with almost 60% of patients in the chemotherapy group. When stratified for only those receiving PARP inhibitors, approximately one-third of patients in the chemotherapy group received a subsequent PARP inhibitor compared with only 4.5% of those administered talazoparib.

“While [progression-free survival] exhibited substantial benefits from talazoparib, [overall survival] can prove a challenge for patients with metastatic breast cancer due to the availability of numerous treatment options,” notes Dr Jennifer Litton, professor of Breast Medical Oncology, who presented results during AACR.

Litton said the later treatments may have affected the results. In fact, other analyses suggest that the OS analysis underestimated the treatment benefit of talazoparib.

For more, visit

NIH Trial Finds Gilead’s Remdesivir Shows Early Promise in Treating COVID-19

The nation’s top infectious disease expert, Dr Anthony Fauci said on Wednesday that an NIH trial for treatment of COVID-19 with remdisivir, an experimental antiviral drug developed by Gilead Sciences, showed that the drug can accelerate recovery in infected patients.

A senior administration official told The New York Times that the FDA is likely to issue an emergency approval for remdivisir. This would be the first approved treatment for COVID-19, which surpassed 1 million infections in the United States this week.

In an earlier news briefing at the White House, Fauci said that findings were very optimistic and “it is a very important proof of concept, because what it has proved is that a drug can block this virus.”

For more, visit

Cost Concerns Would Prevent Millions of Americans From Seeking COVID-19 Care

A new Gallup poll has found that 1 of 7 Americans reported they would avoid seeking healthcare for a fever and dry cough—common symptoms of COVID-19—for themselves or a family member due to cost concerns.

“A pretty substantial chunk of the population could remain hidden from view because of the US healthcare cost crisis,” said Dan Witters, the poll’s research director.

Those most likely to avoid seeking care include:

  • adults under 30 years
  • nonwhite individuals
  • those with a high school education or less, and
  • those residing in households with incomes under $40,000 per year.

According to Gallup, “recent research has shown that millions of Americans know someone who has died in the last 12 months due to their inability to pay for treatment and that $88 billion in borrowing occurred over the last year for healthcare.”

For more, visit

Incorporating V-BID Into COVID-19 Response

The struggle of American families facing the impacts of COVID-19 is the topic of a new interview with Dr Mark Fendrick, co-editor-in-chief of The American Journal of Managed Care® and director of the University of Michigan Center for Value-Based Insurance Design, or V-BID.

Dr Fendrick spoke with AJMC® about how principles of V-BID can be applied during this critical time.

Fendrick explains why it’s important to reduce costs for a broad range of essential health services, not just COVID-19 care, and highlights which changes he sees making a permanent impact even after the pandemic eases.

The interview follows a timely editorial authored by Fendrick and coauthor Beth Shrosbree that calls for expanded coverage of essential care during COVID-19 and beyond.

For the full interview, visit

For the editorial, visit

Expanding Treatment Options for Metastatic Breast Cancer

The University of Kansas Cancer Center featured a Peer-Exchange series hosted by AJMC® titled “Expanding Treatment Options for Metastatic Breast Cancer.”

In the peer-to peer panel discussion, experts review the systemic treatment of metastatic breast cancers and the impact of recent clinical trial data on clinical decision making.

For the full series, visit

Paper of the Week

Now we bring you Paper of the Week, which looks back at research and commentary of the past 25 years in The American Journal of Managed Care® and why it matters today.

A 2017 paper that examined the links between insurance type and delays in care brought some interesting results.

Looking at a large sample from Massachusetts, the first state to mandate health insurance, the authors found that delays in care were more common among middle income consumers with private insurers, due to out of pocket costs, compared with those on Medicaid.

For the full paper, visit

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