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This Week in Managed Care: November 30, 2018


This week, the top managed care news included a CMS plan for changes in drug coverage that brought a wave of criticism; a government task force recommended more people at risk for HIV take pre-exposure prophylaxis, known as PrEP; the American College of Cardiology issued an Expert Consensus Pathway on treatment of patients with type 2 diabetes and atherosclerotic cardiovascular disease.

A CMS plan for changes in drug coverage draws fire, home health agencies will have new rules, and a task force wants more protection for people at risk for HIV.

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

CMS Takes Aim at Drug Prices

CMS officials said they hoped to drive down prices by letting Medicare plans limit coverage for certain key drugs if they become too expensive. But a plan to change the rules for drugs in protected classes brought a wave of criticism Monday, as groups that included the

Community Oncology Alliance accused the administration of “backdoor discrimination.” Some experts predicted lawsuits.

Right now, Medicare Part D plans must cover all drugs in the 6 classes that include all cancer medicines, antidepressants, and HIV drugs. CMS says this makes it difficult to negotiate lower prices, and the proposals would help plans pursue step therapy.

Said Jeff Vacirca, MD, FACP, of the Community Oncology Alliance, “Step therapy requirements are driven by financial interests to save money and not by what is in the best medical interest of patients. … What is the point of having protected therapeutic classes if they are not truly protected?”

Moving Home Health to Value-Based Payments

CMS is moving home health agencies into a new value-based payment system with a new rule that became final this month. Administrator Seema Verma said changes to the Home Health Prospective Payment System will tailor billing to patient needs, enable remote monitoring, and allow home infusion therapy.

Said Verma, “Using new technology and reducing unnecessary reporting measures for certifying physicians will result in an annual cost savings and provide home health agencies and doctors what they need to give patients a personalized treatment plan that will result in better health outcomes.”

CMS expects the new payment model to save 60 million dollars annually as of 2020.

PrEP Recommended

A government task force says more people at risk for HIV should take pre-exposure prophylaxis, the antiviral drugs known as PrEP. The US Preventive Services Task Force has issued a draft recommendation to upgrade PrEP to Grade A, and called for clinicians to offer treatment to people at high risk of contracting HIV.

Task force member Seth Landefeld, MD, said, “The evidence is clear: when taken as prescribed, PrEP is highly effective at preventing HIV. To make a difference in the lives of people at high risk for HIV, clinicians need to identify patients who would benefit and offer them PrEP.”

Despite evidence that PrEP can reduce HIV risk by more than 90% when adherence is consistent, access remains difficult. The draft recommendation noted that 5 states account for 50% of PrEP users.

Preferred Therapy for T2D and ASCVD

The American College of Cardiology this week issued an Expert Consensus Pathway on treatment of patients with type 2 diabetes and atherosclerotic cardiovascular disease. The pathway, published in the Journal of the American College of Cardiology, was endorsed by the American Diabetes Association and reflects results from cardiovascular outcomes trials that have tested new diabetes therapies approved since 2008.

The pathway states that empagliflozin, sold as Jardiance by Boehringer Ingelheim and Eli Lilly, is the preferred SGLT2 inhibitor, and liraglutide, sold as Victoza by Novo Nordisk, is the preferred GLP-1 receptor agonist.

Although cardiovascular disease remains the leading cause of morbidity and mortality in patients with type 2 diabetes, until recently, medications to achieve glycemic control were not expected to offer any cardiovascular benefit.

The authors wrote: “The recent development of 2 novel classes of therapies—SGLT2 inhibitors and GLP-1 [receptor agonists]—has, for the first time, demonstrated that treatments developed for glucose lowering can directly improve outcomes.”

Learn more.

ASH 2018 Coverage

Hematology leaders from around the globe will gather in San Diego this weekend for the 60th meeting of the American Society of Hematology, where results are expected on CAR T-cell therapies, improvements in chemotherapy combinations, and treatments for sickle cell anemia.

AJMC® will have full coverage starting late Saturday, which you can find at the conference page or follow on Twitter, at @EBOncology.

For all of us at the Managed Markets News Network, I’m Laura Joszt. Thanks for joining us.

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