
This Week in Managed Care: November 28, 2015
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
Amid this upheaval, CMS has
- 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
- 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,
The Latest in PCSK9 News
This week,
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
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,
For the Managed Markets News Network, I’m Justin Gallagher. Thanks for joining us.
Newsletter
Stay ahead of policy, cost, and value—subscribe to AJMC for expert insights at the intersection of clinical care and health economics.