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This Week in Managed Care: October 2, 2020


This week, the top managed care news included progress made in diabetes technology coverage and access among Medicare beneficiaries; an inside look into how colleges and universities addressed the COVID-19 pandemic; a recap of the Patient-Centered Oncology Care® 2020 virtual meeting.

Assessing progress made in diabetes technology coverage and access among Medicare beneficiaries, an inside look into how colleges and universities addressed the COVID-19 pandemic, and a recap of the Patient-Centered Oncology Care® 2020 virtual meeting

Welcome to This Week in Managed Care, I’m Matthew Gavidia.

Trump, First Lady Test Positive for Coronavirus

But first, early Friday morning, President Donald Trump tweeted that he and First Lady Melania Trump had tested positive for SARS-CoV-2, the virus that causes coronavirus disease 2019, known as COVID-19. The news came just hours after one of his closest advisors had tested positive.

Trump has spent most of 2020 downplaying the threat of COVID-19, which has killed more than 205,000 Americans. He and the first lady are now in quarantine, plunging the country deeper into uncertainty 32 days before the presidential election.

Shortly after news broke, Vice President Mike Pence and Secretary of State Mike Pompeo had tested negative. Democratic candidate Joe Biden, who debated the president on Tuesday night, will also get tested on Friday.

For updates on this story, visit ajmc.com.

Progress Made in Diabetes Technology Coverage, Access Among Medicare Beneficiaries

Recently, 2 district courts secured a pair of victories for Medicare beneficiaries who use continuous glucose monitor, or CGM, technologies to manage their diabetes.

On September 23, the United States Court of Appeals for the Second Circuit ruled that Medicare beneficiaries can combine claims denied by Medicare to meet the dollar amount necessary for judicial review, according to a press release from Parrish Law Offices.

The case, Bloom v Azar, was brought by a Medicare beneficiary, Jonathan Bloom, who used a CGM to manage his type 1 diabetes and sought coverage to offset the CGM costs. However, Bloom was denied coverage by the Medicare Appeals Council and challenged that decision.

Previously, the Third District Court ruled that Medicare must cover CGMs, but ruled 2 of the 3 challenged decisions did not meet the $1500 amount-in-controversy threshold for federal court jurisdiction.

However, “the Second Circuit held, based on the text of the statute and reinforced by its regulatory and legislative history, that the Medicare Act does not prohibit the plaintiff from aggregating his claims for the first time in district court,” according to Justia Law. The findings ultimately allowed for recovery on all 3 claims.

In a separate case, Zieroth v Azar, the District Court for the Northern District of California found Medicare’s claim that CGMs are not “primarily and customarily used to serve a medical purpose” unreasonable and not entitled to deference. The court ordered coverage of CGM claims, reflecting the Fourth District Court’s previous ruling that Medicare’s position is contrary to law.

Although these rulings mark a step in the right direction for patients, Medicare beneficiaries still face significant hurdles securing access to CGM technology, Parrish Law Offices states, as Medicare and Medicare Advantage plans continue to deny coverage of some CGMs. A class action lawsuit has been filed in the District of Columbia seeking coverage as far back as 2012 for beneficiaries whose CGM claims were denied.

For more, visit ajmc.com.

How Have Colleges, Universities Addressed the COVID-19 Pandemic?

In late February and early March, colleges and universities were tasked with the responsibility of addressing the health and economic threats precipitated by the COVID-19 pandemic.

Involved in these discussions, Dr Dennis Scanlon, distinguished professor of Health Policy and Administration at Penn State University, associate editor of The American Journal of Managed Care®, and editor-in-chief of The American Journal of Accountable Care®, helped advise the university on returning to residential instruction and education for the fall of 2020.

In an interview with AJMC®, Scanlon speaks on the myriad factors that were considered when deciding how to reopen, particularly in prioritizing the safety of students, faculty, and community members, as well as the quality of education delivered.

“At most places, [it] has been all hands on deck. People have given up sort of their day jobs or a significant portion of their day jobs to help out, and everybody’s been trying to learn in an uncertain environment where oftentimes the recommendations or suggestions can be conflicting,” said Scanlon.

For more, visit ajmc.com.

Patient-Centered Oncology Care® 2020

This past week, The American Journal of Managed Care® held its 9th annual Patient-Centered Oncology Care®, or PCOC®, 2020 meeting in a virtual format.

AJMC.com provided full coverage of the virtual meeting, which took place September 25.

Kicking off the meeting, event co-chair Dr Kashyap Patel, who is CEO of Carolina Blood and Cancer Care Associates of Rock Hill, South Carolina, spoke on the current state of cancer care.

“We are living in a totally different world,” said Dr Patel, as he introduced keynote speaker Dr Alexandra Chong, who serves as lead for the Oncology Care Model, or OCM, within the Center for Medicare and Medicaid Innovation. “What we are learning is how COVID-19 impacts not just us as what we do in the office, but how it impacts the rapid adaptation and changes from the payer perspective.”

In addressing the hundreds of online attendees, Chong noted that nothing about taking care of patients with cancer during the COVID-19 pandemic has been easy, but those practices that had already embraced transformation under the OCM are finding that its monthly payments and other features offer stability during an unprecedented health emergency.

For all the preconference videos and coverage of the virtual meeting, visit ajmc.com.

Moderna SARS-CoV-2 Vaccine Elicits Response in Older Adults

This week, a small phase 1 study of 40 adults over age 56 years found that Moderna’s 2-shot mRNA-1273 vaccine against SARS-CoV-2, the virus that causes COVID-19, showed binding antibody responses similar to those previously reported in younger adults.

In this trial of older adults, 2 subgroups of 40 adults (nearly all White) were stratified by age 56 to 70 years or 71 years and older, they received 2 doses 28 days apart of either 25 mcg or 100 mcg.

The results, which were published Tuesday in The New England Journal of Medicine, also show that the response following the second dose was similar to those in patients who were infected, recovered, and donated convalescent plasma.

The most powerful effect was seen with the 100-mcg dose, which is being tested in a phase 3 study, enrolling 30,000 adults, that began at the end of July.

The study is being conducted in 3 centers—Kaiser Permanente Washington Health Research Institute, the Emory University School of Medicine, and the National Institute of Allergy and Infectious Diseases Vaccine Research Center.

The Moderna candidate is 1 of 11 SARS-CoV-2 vaccines in the later stages of testing.

For more, visit ajmc.com.

Paper of the Week

And, now our paper of the week, which looks back at some of the most important papers over the past 25 years of The American Journal of Managed Care® and why they matter today.

The 2004 Translating Research Into Action for Diabetes (TRIAD) study measured the effects of “gatekeeping,” also known as referral management, on patients with diabetes.

While strategies to ensure that patients stayed in a certain network have often been criticized, the study found that these efforts had little effect on the rates of how many patients received eye exams, or the perception of how hard it was to get in to see a specialist among patients with diabetes.

For the paper, visit ajmc.com.

For all of us at AJMC®, I’m Matthew Gavidia. Thanks for joining us!

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