This Week in Managed Care: November 8, 2019

November 8, 2019

This week, the top managed care news included CMS started planning for life after the Oncology Care Model; a judge blocked a rule requiring immigrants to have health coverage; Election Day brought news for Medicaid work rules.

CMS starts planning for life after the Oncology Care Model, a judge blocks a rule requiring immigrants to have health coverage, and Election Day brings news for Medicaid work rules.

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

CMS Seeks Feedback on OCM Successor

Last Friday, the Center for Medicare and Medicaid Innovation (CMMI) surprised the oncology community with a request for information on a proposed successor to the Oncology Care Model, the 5-year alternative payment model that expires in 2021.

While there’s been speculation what will come next, the request caught stakeholders off guard, since comments are due November 25th.

Elements of the working model, called Oncology Care First (OCF), include:

  • A prospective, monthly population payment for the practice or hospital’s Medicare fee-for-service population with cancer. The payment will include evaluation and management services, as well as “enhanced services.”
  • Accountability for total cost of care, including drugs, incurred over a 6-month episode.
  • Electronic patient-reported outcomes (PROs) will be added as a required activity.
  • Changes to make attribution more predictable at the start of an episode; episodes will be attributed to the physician group practice as long as the participant bills at least 25% of the cancer-related E/M services.

A listening session held Monday brought out well-known stakeholders in cancer care to pinpoint challenges with both the proposal and CMMI’s process.

Said Ted Okon of the Community Oncology Alliance, “It is completely unreasonable for oncology practices and stakeholders to adequately assess and provide detailed feedback on the OCF within the time CMMI has allotted. Three weeks is too short a time for meaningful input.”

Kashyap Patel, MD, of Carolina Blood and Cancer Care Associates, who is associate editor of Evidence-Based Oncology™, warned that some patients lack the technology needed for electronic PROs. He said, “Half of my patients still use a flip phone.”

And Barbara McAneny, MD, a former president of the American Medical Association who also treats many low-income patients, told CMMI leaders they should look to the payment model she devised, Making Accountable Sustainable Oncology Networks, for ideas on how to address high drug costs.

Trump's Immigrant Health Insurance Rule Blocked

US District Judge Michael Simon of Oregon suspended the Trump administration’s rule telling immigrants they must prove they will have health insurance or pay for medical coverage before they can get a visa.

Simon granted a temporary restraining order but it is unclear how he will rule in the case. The matter was brought by 7 US citizens and a nonprofit, who argued the rule might block up to two-thirds of all prospective legal immigrants.

Simon wrote: "Congress has spoken directly to the circumstances in which an individual may be deemed to become a ‘financial burden’ to the United States and has rejected the Proclamation’s core premise.”

Election Wins on Medicaid Promises

Kentucky Governor Matt Bevin lost his re-election bid Tuesday in a race that turned in part on his changes to Medicaid expansion, including work rules.

The apparent winner, Attorney General Andy Beshear, vowed to rescind the work requirements and restore the program that his father, former Governor Steve Beshear, installed shortly after the Affordable Care Act took effect.

Democrats also took control of the state legislature in Virginia, which will let Governor Ralph Northam end work requirements that were struck in a deal with Republicans in order to expand Medicaid in the commonwealth.

Cost-Effectiveness of Type 2 Diabetes Treatment

A nonpartisan research group has found that the type 2 diabetes drug empagliflozin is more cost-effective than oral semaglutide, which gained noticed when it received FDA approval in September.

Oral semaglutide, the first glucagon-like peptide-1 receptor agonist available as a pill, is considered a breakthrough by many researchers and payers.

But the Institute for Clinical and Economic Review (ICER) found that its cost, which is on par with other injectables, and its side effects make it a less attractive a choice than the sodium glucose cotransporter 2 (SGLT2) inhibitor empagliflozin, which has been on the market for 5 years.

Said David Rind, MD, ICER’s chief medical officer,

“…judging from the list price of oral semaglutide, its net price is likely to be much higher than that of competitor oral treatments, including the SGLT2 inhibitor empagliflozin that appears to have similar benefits with fewer common side effects.”

The ICER report found the net price for oral semaglutide per 30 days was $501, compared with a net price of $174 for empagliflozin.

Read more.

UnitedHealthcare Requires Biosimilar Switch for Anemia Drug

The American Journal of Managed Care® (AJMC®)'s sister site the Center for Biosimilars®, reports that UnitedHealthcare patients who are taking epoetin alfa will be required to switch to Pfizer’s biosimilar Retacrit, unless they meet medical necessity criteria. Coverage for Retacrit will not require prior authorization for patients who meet criteria, for various indications of anemia.

For the full article, visit The Center for Biosimilars®.

For all of us at AJMC®, I’m Laura Joszt.

Thanks for joining us.