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This Week in Managed Care: May 4, 2018


This week, the top managed care stories included a report that insurance coverage gains are reversing; a deal to lower the cost of Praluent for Express Scripts members; findings that synthetic opioids are playing a bigger role in overdose deaths.

Insurance coverage rates are falling, Express Scripts makes a deal on a cholesterol drug, and synthetic opioids are overtaking prescription drugs in opioid-related deaths.

Welcome to This Week in Managed Care, I’m Laura Joszt.

Insurance Coverage Gains Start Reversing

The rate of Americans who lacked health insurance reached an all-time low after the Affordable Care Act (ACA) passed, but things are moving the other way, according to a report from the Commonwealth Fund.

This week’s report finds that the uninsured rate among low-income adults rose from 20.9% in March 2016 to 25.7% in March 2018, based on several factors:

  • The failure to shore up weaknesses in the ACA
  • Confusion about the status of the law
  • A lack of advertising during open enrollment

President Donald Trump’s repeal of the individual mandate in the new tax law and Medicaid work requirements in some states are expected to increase the uninsured rate even more, according to the report.

Learn more.

Lower Cost, Easier Access for Praluent

Praluent, 1 of 2 powerful cholesterol drugs called PCSK9 inhibitors, will soon be less expensive and easier to get for consumers who use Express Scripts, following a deal announced this week.

Drug makers Sanofi and Regeneron announced price cuts and an exclusive formulary deal with Express Scripts, which agreed to end the complex preapproval process that cardiologists had to follow to get the drug for their patients.

Praluent, which cost more than $14,000 a year, will be priced in line with benchmarks set by the Institute for Clinical and Economic Review. In March, its analysis found that Praluent should cost 50% to 75% less for most patients who meet FDA criteria.

Last year, Sanofi’s Jay Edelberg, MD, told AJMC® about difficulties patients and doctors were experiencing. Watch the interview.

Part of the manufacturer’s rebate will now go directly to consumers to offset out-of-pocket costs.

Read more.

Overdose Deaths and Synthetic Opioids

Synthetic opioids are catching up to prescription opioids as the most common drug involved in overdose deaths.

A new report in JAMA by officials from the National Institute on Drug Abuse said that about one-seventh of opioid deaths in 2010 involved a synthetic drug. By 2016, 45% of all recorded deaths from opioids involved a synthetic drug. However, the authors said the actual number is likely higher due to limited information on death certificates.

Prescription opioid use is dropping, thanks to greater awareness and pharmacy monitoring programs. However, doctors worry that Medicare patients with cancer who are in pain are being adversely affected.

The authors wrote: “Widespread public health messaging is needed, and clinicians, first responders, and lay persons likely to respond to an overdose should be trained on synthetic opioid risks and equipped with multiple doses of naloxone. These efforts should be part of a comprehensive strategy to reduce the illicit supply of opioids and expand access to medication-assisted treatment for opioid addiction.”

Second Indication for CAR T-Cell Therapy Kymriah

Novartis’ CAR T-cell therapy Kymriah received a new indication this week, as FDA approved the treatment for adult patients with relapsed or refractory large B-cell lymphoma.

The approval includes patients with specific forms of large B-cell lymphoma who have not responded to at least 2 other treatments and have limited treatment options. Kymriah will compete with Gilead’s Yescarta, which was approved in October to treat these patients. Kymriah was first approved last August to treat pediatric acute lymphoblastic leukemia.

Politics at World Health Care Congress

Finally, AJMC® spent this week covering the World Health Care Congress, where CMS Administrator Seema Verma said her agency is fostering competition in the markets and working to get patients access to their healthcare information.

“We made it clear that the days of finding creative ways to track data in closed systems must come to an end. It is no longer acceptable to limit patient records or prevent them and their doctors form seeing their complete history.”

Former HHS Secretary Tom Price acknowledged the repeal of the individual mandate brought some market instability, but said that he believes that the Affordable Care Act has now stabilized. He said patients on the exchanges are sicker and use more healthcare than most people.

Asked Price: “Are these exchanges the de facto high-risk pools that many people talked about being necessary [but] without the efficiency or true planning of a high-risk pool?”

Check out full coverage of the World Health Care Congress.

For all of us at the Managed Markets News Network,

I’m Laura Joszt, Thanks for joining us.

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