This Week in Managed Care: November 15, 2019

This week, the top managed care news included Medicaid tightening the reins on supplemental payments; employers needing more data to control benefit costs; experts saying prior authorization mostly burdens patients.

Medicaid tightens the reins on supplemental payments, employers need more data to control benefit costs, and experts say prior authorization mostly burdens patients,

Welcome to This Week in Managed Care, I’m Christina Mattina.

Medicaid Changes

CMS Administrator Seema Verma unveiled a plan for greater transparency in how states spend Medicaid dollars, as her agency proposed new rules to tighten up so-called supplemental payments to hospitals, nursing homes, and doctors.

Speaking before the National Association of Medicaid Directors, Verma also defended Medicaid work rules that have been challenged in court.

On the proposed requirements, she said, “We have seen a proliferation of payment arrangements that mask or circumvent the rules. Shady recycling schemes drive up taxpayer costs and pervert the system by shifting resources away from higher value settings.”

Verma offered some examples:

  • Payments have climbed for governmental providers that can self-fund the state match to levels that exceed Medicare payments, with little connection to the health of beneficiaries.
  • Local governments use tax dollars to fund the state match, which Verma said create abuses when taxpayers shoulder additional costs while creating unfair competition.

Managing Healthcare Costs in 2020

Employers, meanwhile, have made reigning in health benefit costs a priority but may lack enough data to make progress. That’s the conclusion of First Stop Health’s inaugural Health Benefits Cost Containment Report, which offered feedback following a survey of human resource professionals.

The report found that healthcare spending is expected to rise at least 5% a year through 2027, and low unemployment has created competition for workers based on benefits.

David Guttman of First Stop Health said employers have a difficult time measuring the impact of benefits: “If you can’t measure it, you can’t improve it. The report shows that employers find it difficult to measure the impact of their benefits. In fact, less than half of employers surveyed measure the ROI of most benefits.”

Guttman said not every new benefit will improve health outcomes and employers must be careful when looking for innovative solutions.

Read more.

Prior Authorization and Step Therapy

Doctors and patients alike dislike prior authorization for new drugs, and two experts say the process is more than an inconvenience.

Jessica Farrell, PharmD, and Madeline Feldman, MD, FACR, said utilization management—which can include prior authorization or step therapy—can lead to worse outcomes for patients. The pair spoke at this week’s meeting of the American College of Rheumatology, and said delays in a getting a drug approved result in patients not getting therapy in a timely manner, even if it is later authorized.

Examples of the effects on patients include:

  • Patients whose infusible therapy required prior authorization saw treatment delayed by four extra days, compared with those who did not need authorization.
  • A recent study showed that when a prior authorization is denied initially, treatment with an infusible medicine can be delayed for 50 days.

See full coverage from the American College of Rheumatology meeting.

Kidney Week Coverage

AJMC® also traveled to Washington, DC, to Kidney Week, presented by the American Society of Nephorology.

Attendees heard data from cardiovascular trials for roxadustat, an investigational therapy to treat anemia in patients with chronic kidney disease, as well as information about new value-based kidney care models from the Center for Medicare and Medicaid Innovation.

The Center for Medicare and Medicaid Innovation's Kidney Care Choices will run from 2020 until December 2023 with an option to extend up to 2 years. Those options include:

  • Kidney Care Choices, an optional model aimed at providers and practices that would run from 2020 through 2023,
  • Kidney Care First, would aims to bring down the total cost of dialysis and improve care coordination through the use of bonus payments,
  • Comprehensive Kidney Care Contracting, which features 3 different options for larger kidney care entities.

See more from Kidney Week.

Vascepa and AHA Coverage

FDA staff gave a mostly positive review to the request for a cardiovascular indication for Vascepa, the fish oil—derived drug to control triglycerides.

Some experts still have questions about the design of the trials that produced blockbuster results for Amarin’s pill last year at the American Heart Association (AHA).

Following Thursday’s scheduled meeting of an FDA advisory committee on the request, more data on Vascepa will be presented at this weekend’s AHA Scientific Sessions, which take place November 16 to 18 in Philadelphia.

Besides updates on Vascepa, visit for the following:

  • Details on the DAPA-HF trial, which found that the sodium-glucose cotransporter-2 inhibitor dapagliflozin can prevent heart failure in some at-risk patients even without diabetes.
  • A readout of the ISCHEMIA study, which seeks to settle the question of whether invasive procedures like stents work better than medication for patients with blockages.

See full coverage of the meeting this weekend.

For all of us at AJMC®, I’m Christina Mattina. Thanks for joining us.

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