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This Week in Managed Care: November 24, 2017


This week, the top managed care stories included a new rule from CMS to address drug costs for seniors; a campaign to get payers to fund the artificial pancreas is working; and a new survey identifies how Americans prefer to treat pain.

CMS takes aim at drug costs for seniors, a campaign to get payers to fund the artificial pancreas is working, and a new survey shows how Americans prefer to treat pain.

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

Medicare Drug Costs

President Trump has vowed to do something about high drug costs, and this week CMS proposed a rule that would go after high costs in Medicare. The new rule takes several steps to address high costs and lack of choice for seniors, while including a provision to fight the opioid epidemic.

The proposals include:

  • Revised maximums on out-of-pocket limits.
  • Changing rules to let seniors pick their pharmacy.
  • Allowing mid-year changes to plans to add generics.
  • Treating biosimilars like generics for pricing purposes.
  • Requiring health plans and drug companies to submit information about discount programs—and how these rebates affect consumer prices.

The rule would also allow Medicare Advantage plans to identify patients at-risk of opioid addiction and restrict their access to the drugs.

Read the full story.

Artificial Pancreas Coverage

Payers were not sold on Medtronic’s artificial pancreas when it first reached the market last spring, which disappointed diabetes advocacy groups that had waited years for this technology, which largely frees people with type 1 diabetes from having to make insulin dosing decisions.

JDRF, which promotes research and advocacy for people with type 1 diabetes, this week announced a policy change from Anthem thanks to its Coverage 2 Control campaign, which calls on payers to cover the artificial pancreas and lower out-of-pocket expenses for people with diabetes.

Anthem now joins Aetna, Humana, Kaiser Permanente, Medica, and Blues plans in six states in covering the artificial pancreas.

Said JDRF President Derek Rapp: “I am so proud of how the Coverage2Control campaign helped make this happen. We applaud Anthem for this decision, and will continue to push insurers to make changes to coverage that enable better diabetes management.”

Pain Management Preferences

Nearly two-thirds of American adults have had neck or back pain severe enough to see a healthcare professional at some point, according to findings from Gallup and Palmer College of Chiropractic.

Seventy-eight percent prefer to find some way other than drugs to relieve the pain, such as spinal manipulation, acupuncture, or physical therapy, but little is known about their attitudes or experiences with treatments.

According to the report: “US adults are most likely to want to see a medical doctor for significant neck or back pain while about 1 in 4 would prefer to see a chiropractor over other healthcare professionals. Far fewer say they would most like to see a physical therapist, an acupuncturist, or a massage therapist for significant neck or back pain.”

The report found that 55% of adults were likely to see a chiropractor if they had severe neck of back pain, and nearly 62 million Americans had seen a chiropractor in the past 5 years.

The most common reasons for not seeing a chiropractor were:

  • Having another healthcare provider (33%)
  • Not trusting chiropractors (29%)
  • Not thinking chiropractic care is safe (23%)

TAPUR Study Expands

The American Society of Clinical Oncology (ASCO) announced this week that it is expanding the TAPUR study to include immunotherapy combinations.

This study, which uses FDA-approved drugs with new indications, provides patients access to drugs at no cost and now includes 500 patients and 16 different therapies.

Said ASCO’s Richard Schilsky, MD, FACP, FASCO: “This study just reached a key milestone and we're excited to explore these treatments further. While no conclusions about drug efficacy should be drawn at this point, we are very pleased with the growth and expansion of the TAPUR Study.”

New arms of the study include:

  • patients with ovarian cancer being treated with cetuximab
  • Patients with breast cancer with a high tumor mutation being treated with pembrolizumab
  • patients with colorectal cancer with a BRAF V600E mutation being treated with a combination of vemurafenib plus cobimetinib

Cardiovascular Prevention

Finally, this month’s issue of The American Journal of Managed Care® features a study that shows increases in some cardiovascular preventive services after the start of the Affordable Care Act.

Joseph A. Ladapo, MD, PhD, and Dave A. Chokshi, MD, MSc, found increases in diabetes and hypertension screening, and especially in tobacco screening after a change in cost-sharing requirements.

Read the full study.

For all of us at the Managed Markets News Network,

I’m Laura Joszt, thanks for joining us.

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