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This Week in Managed Care: September 12, 2015


The top stories in managed care this week include value-based pricing of the new PCSK9 inhibitors, CMS unveiled a new health equity plan for Medicare, and the American Medical Association released analyses on proposed health insurance mergers.

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.

PCSK9: Value-Based Pricing

This week a new report found that the price of PCSK9 inhibitors, Repatha and Praluent, should be much less than the announced $14,000 a year.

The Institute for Clinical and Economic Review said the new cholesterol-lowering drugs would be cost-effective if they were priced at 85% less than what will be charged per patient in the US.

It has been estimated that as many as 3.5 to 15 million Americans with elevated cholesterol may be eligible for treatment with PCSK9 inhibitors. But, according to the report, these new drugs would have to come down to an annual cost of $2,177 for the price to be at a level where doctors and insurers would not try to limit patient use in some way.

Price Transparency Efforts

A new issue brief from America’s Health Insurance Plans takes a look at price transparency efforts, barriers to improving transparency, and structuring future initiatives.

Health plans and employers are hoping to improve efficiency, clinical effectiveness, and value of healthcare through the availability and use of healthcare cost information. However, in order for these initiatives to be successful that price information needs to be paired with quality information, according to AHIP.

Recently, health economist Austin Frakt discussed the same issue with The American Journal of Managed Care. Watch the video.

Ensuring Health Equity

The federal government is taking steps to ensure vulnerable populations—such as ethnic, racial, and gender minorities, and people with disabilities—have equal access to healthcare and health coverage in the United States.

As part of its celebration of 50 years of Medicare, CMS unveiled a plan to address health equity in the program. The plan includes 6 priority areas aimed at reducing disparities over the next 4 years in populations that experience disproportionately high burdens of disease, lower quality of care, and barriers to access to care.

Cara James, director of the CMS Office of Minority Health said, “Making sure care is equitable is often the forgotten core area of focus for ensuring that the health system is meeting patient needs and delivering high quality care.”

Last week, HHS released a proposed rule that would extend all civil rights obligations to the health insurance marketplaces and HHS health programs and activities. The rule establishes that the prohibition on sex discrimination includes discrimination based on gender identity.

Health Insurer Consolidation

The American Medical Association has determined that the potential mergers between Aetna and Humana, and Anthem and Cigna will reduce competition in nearly half of the country.

If approved by regulators, the proposed mergers would reduce the top 5 health insurers in the US down to just 3. In a total of 23 states, and more than 100 metropolitan areas, the mergers raise significant competitive concerns, according to the reports. Given the results of the analyses, AMA is urging regulators to carefully review the proposed mergers and preserve competition.

"If a health insurer merger is likely to erode competition, employers and patients may be charged higher than competitive premiums, and physicians may be pressured to accept unfair terms that undermine their role as patient advocates and their ability to provide high-quality care,” said AMA President Dr Steven J. Stack.

Psych Congress 2015

Finally, this week The American Journal of Managed Care is in San Diego covering the annual meeting of the US Psychiatric & Mental Health Congress.

You can find the full coverage, such as sessions on addressing non-adherence in bipolar illness, the current state of antidepressant therapy, and using telemedicine to treat PTSD, at our conference page. And don’t forget to sign up for our e-mail to have articles and interviews from conferences sent directly to your inbox.

For everyone at the Managed Markets News Network,

I’m Justin Gallagher.

Thanks for joining us.

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