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This Week in Managed Care: November 4, 2016


This week, the top stories in managed care included the new Physicians' Fee Schedule released by CMS, a focus on a ballot question in California regarding drug spending, and Patient-Centered Oncology Care announced keynote speaker Roy Beveridge, MD.

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

Physicians' Fee Schedule

CMS this week released the final 2017 Physicians’ Fee Schedule, including payment reforms in primary care, behavioral health, and diabetes prevention.

Starting in January, physicians will have new billing codes for:

  • Complex chronic care management
  • Mental health services in a primary care setting
  • Assessment and care planning for patients with Alzheimer’s or other cognitive impairments

Paying for Diabetes Prevention

CMS also finalized eligibility rules for the Medicare Diabetes Prevention Program, which will begin January 1, 2018. Federal officials estimate that Medicare will spend an extra $42 billion on beneficiaries with diabetes in 2016, highlighting the need to slow the number of seniors with prediabetes who progress to the disease.

For now, diabetes prevention programs must have full CDC recognition to be paid by Medicare, although this requirement may be revisited. Payment schedules will not be final until 2017.

To take part, seniors must have a BMI of at least 25 and have other health indicators of prediabetes.

For more on CMS’ eligibility criteria, read the article.


Besides the Physician’s Fee Schedule, CMS will be testing new value-based cost-sharing models in chronic conditions in 2017. AJMC co-editor-in-chief A. Mark Fendrick, MD, who is the director of the Center for Value-Based Insurance Design at the University of Michigan, discussed what’s coming in Medicare Advantage. Watch the interview.

Drug Expenditures in California

With Election Day coming on Tuesday, most voters are focused on the race for president. But many cities and states have important ballot questions, especially in California.

The pharmaceutical industry is fighting Proposition 61, which would limit what state agencies pay for prescription drugs. The measure would tie what the state spends to prices paid by the Veterans’ Administration, which spends less than any federal agency for drugs.

Supporters say passage would bring savings for patients and taxpayers, but others say it’s hard to predict how drug manufacturers would respond. As the campaign entered its final week, the two sides had raised more than $125 million to promote their positions.

For more on the ballot question, read the article.

PCOC Keynote: Dr Roy Beveridge

Roy Beveridge, MD, chief medical officer of Humana, will be the keynote speaker at Patient-Centered Oncology Care, which will meet November 17-18 in Baltimore, Maryland. Dr Beveridge, who was previously with US Oncology, is a long-time advocate for advancing payment reform.

He wrote, “The Path to Value Through the Use of Holistic Care,” for AJMC’s 20th anniversary commentary series in 2015.

To learn more, and to join us for Patient-Centered Oncology Care, visit the meeting page.

For all of us at the Managed Markets News Network, I’m Justin Gallagher. Thank you for joining us.

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