This Week in Managed Care: November 21, 2015

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The top stories in managed care were discussions of value-based care at the NAMCP Fall Managed Care Forum, hospitals are suing over Horizon Blue Cross Blue Shield of New Jersey's OMNIA plan, and CMS finalizes its bundled payments for joint replacement.


Hello, I’m Justin Gallagher, associate publisher of The American Journal of Managed Care. Welcome to This Week in Managed Care, from the Managed Markets News Network.

March Toward Value-Based Care

Managed care experts from around the country gathered in Las Vegas last week for the Fall Managed Care Forum, presented by the National Association of Managed Care Physicians. (See the full conference coverage here.)

Keynote speaker Dr Jacque Sokolov, chairman and CEO of SSB Solutions, said that government is leading the way into value-based care, particularly in Medicare, which will force others to follow.

He discussed the challenges facing ACOs, which suffer when their patient population fluctuates during the year. Said Dr Sokolov: “If you don’t know who you’re managing, you’re really going to have a hard time managing them.”

Dr Sokolov also discussed the controversy surrounding Horizon Blue Cross Blue Shield of New Jersey, which has found resistance to its OMNIA plan. While some experts credited Horizon for making an effort to advance population health and cut costs, the plan faced criticism for excluding several hospitals that serve the poor. Horizon has also been criticized for a lack of transparency in creating the network.

This week, St. Peter’s Hospital of New Brunswick won the right to a court hearing, where Horizon will have to reveal why it did not include the Catholic hospital in OMNIA. The hearing is set for December 17. In addition, 17 hospitals are suing state regulators to block the OMNIA plan.

Bundled Payments in Joint Replacement

In a move toward value-based care, CMS this week finalized a rule to require bundled payments for hip and knee replacements in 67 markets. These surgeries are among the most common in Medicare, and can cost between $16,500 and $33,000, depending on the location.

Under the new model, hospitals will be accountable for the surgery and all related costs through 90 days after discharge. Hospitals that meet quality and cost targets can earn rewards, but some may have to return money. The new model starts April 1st in 2016.

Opioid Measures

The opioid epidemic has drawn attention from the nation’s top health officials and public policy makers. To help combat the problem, the Pharmacy Quality Alliance has recently established a set of measures to strike a balance between individual patient needs and trends that could be a sign of problems. Watch the interview with Dr Woody Eisenberg.

FDA Regulation of Laboratory-Developed Tests

The FDA issued a report this week that paves the way for regulation of laboratory-developed tests—which cost Medicare $9.7 billion in 2012 and are widely used to make clinical decisions. The tests, known as LDTs, are typically designed and used within a single laboratory, and until now have been beyond FDA’s reach. Tests that do not need FDA clearance only require oversight by CMS, under the Clinical Laboratory Improvement Amendments.

The new report offers 20 cases studies that show potential harm to patients because of gaps in today’s regulations.

SGLT2s in Type 1 Diabetes

Can SGLT2s be used to treat type 1 diabetes? That’s the question researchers are trying to answer.

This new drug class, approved to treat type 2 diabetes in 2013, has already been shown to have benefits beyond lowering A1C. In the current issue of Evidence-Based Diabetes Management, experts say the unique mechanism of action may prove beneficial for patients with type 1 disease. Read the full story.

For everyone at the Managed Markets News Network, I’m Justin Gallagher. Thanks for joining us.