This Week in Managed Care: November 28, 2015

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This week in managed care, CMS proposed changes to the health insurance marketplaces for 2017, AJMC highlights 5 takeaways from the HHS Pharmaceutical Forum, CVS chose to cover just 1 PCSK9, and industry reacts to FDA regulating diagnostic tests.


Transcript (slightly modified)

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.

CMS Proposes Changes to ACA Marketplaces

The first few weeks of open enrollment under the Affordable Care Act have been surrounded by unsettling news. Co-ops that provided low cost coverage are failing, and UnitedHealth Group is threatening to pull out of the federal health insurance marketplaces.

Amid this upheaval, CMS has proposed changes for next year to improve the marketplaces. Insurers and the public are invited to comment on proposals that are designed to

  • Streamline direct enrollment
  • Lower administrative burdens for payers
  • Keep user fees stable for 2017
  • And, amend the risk adjustment formulas to ensure greater accuracy

HHS Pharmaceutical Forum

Last Friday, HHS held a one-day Pharmaceutical Forum, which sought ways to deliver high-quality affordable healthcare. AJMC identified 5 important takeaways from the meeting:

  • All stakeholders want to move to value-based contracting
  • Discussing value is complicated, because there are many ideas of what value means.
  • Everyone wants more transparency in more areas of care.
  • Access to drugs does not have to be absolute.
  • Patients want national action to curb the high cost of drugs.

To learn more about the Pharmaceutical Forum, read the story.

The Latest in PCSK9 News

This week, CVS announced it had reached an agreement to add only one PCSK9 inhibitor to its formulary. Repatha, from Amgen, gained an exclusive deal with the nation’s second-largest pharmacy benefits manager, 6 weeks after Express Scripts agreed to cover both cholesterol fighting drugs.

While terms of neither deal have been released, both likely involve discounts to the original list prices, which were above $14,000 a year when the 2 drugs were approved this summer.

Pharmacy benefit managers have fought back against these high costs, with Harvard Pilgrim requiring Amgen to bear some risk in case the drug does not work. In Great Britain, a watchdog agency recommended that the National Health Service not cover the drug due to its price, even though it’s far less expensive in Europe.

Meanwhile, competitors Sanofi and Regeneron announced they had enrolled 18,000 people in a long-term cardiovascular outcomes trial for the other PCSK9 inhibitor, Praluent.

FDA Regulation of Diagnostic Tests

Last week, The American Journal of Managed Care hosted Patient Centered Oncology Care in Baltimore, Maryland, and the best-received panel discussion involved FDA’s possible plans to regulate laboratory developed tests. Dr Scott Gottlieb, a former FDA official who is now with the American Enterprise Institute, told AJMC he’s generally not in favor of regulation, although there are some limited cases where it might make sense. Watch the video interview.

Penalties for Routine Prostate-Cancer Screening

Finally, reaction to value-based care isn’t always positive. CMS recently drew several hundred comments—most of them negative—when it proposed penalties for physicians who order routine prostate-cancer screening tests.

The US Preventive Services Task Force recommended against the routine screening a few years ago, although that decision was widely criticized by several professional groups. Most recommend that doctors discuss the benefits and risks of tests with their patients. While prostate cancer causes 28,000 deaths each year, there is also evidence that too much aggressive testing and treatment can cause harmful side effects. For insight into the controversy over prostate cancer screening, read our story.

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