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This Week in Managed Care: September 14, 2018


This week, the top managed care news included medical groups asking CMS to halt or slow down its plans to cut physician reimbursement for evaluation and management services; the Senate weighs a package of bills to combat the opioid epidemic; new research shows the Affordable Care Act pushed the uninsured rate down to 10%.

Doctors ask CMS to shelve proposed payment rules, the Senate weighs bills to fight the opioid epidemic, and a study finds how many people became insured under the Affordable Care Act.

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

Responding to Proposed Physician Fee Schedule Changes

Groups of physicians say CMS is moving too quickly with a plan to overhaul Medicare reimbursement rates for offices.

The American College of Physicians was among the groups filing comments this week, arguing that a plan to fold rates for 8 different service levels into just 2 would have unintended consequences. The rates, called “evaluation and management,” allow doctors to bill more if patient needs are more complex.

ACP also said that current scoring systems under the Quality Payment Program are too complex, and doctors lack other options. It wrote: “We call on CMS to drastically expand opportunities for participation in Advanced [Alternative Payment Models.]”

The American Society of Clinical Oncology (ASCO) protested the rate plan, as well as proposed reimbursement cuts to an add-on rate for complex cancer drugs administered in physician offices.

Said ASCO President Monica Bertagnolli, MD, FACS, FASCO: “We urge CMS to refrain from finalizing any proposals that would result in any cuts in payments for cancer services and to work collaboratively with ASCO to implement global payment reforms, including the development and implementation of new [alternative payment models] that are widely available to all cancer professionals.”

Opioid Bills

The Senate may soon pass a package of bills to curb opioid abuse. A substitute amendment is being crafted in place of the package that cleared the House in June. The bills include:

  • A measure to stop shipment of fentanyl and other opioids from China through the mail.
  • A rule that would let FDA require opioids to be sealed in plastic blister packs.
  • A bill to let Medicaid pay to treat infants born with opioid exposure at special treatment centers.

The package would also expand the use of telehealth services for addiction treatment.

Coverage Impact of ACA

A study funded by the Robert Wood Johnson Foundation shows that the nation’s uninsured rate fell from 18% to 10% from 2013 to 2016, due to the Affordable Care Act.

Medicaid expansion drove coverage gains, and increases were higher in the 31 states that expanded coverage beyond the traditional population. The study found:

  • In expansion states, 12.6 million people gained coverage, including 9.7 million in Medicaid.
  • In expansion states, the uninsured rate dropped by half, from 15.3% to 7%.
  • In nonexpansion states, the uninsured rate fell from 19.8% to 13.7%, and 5.9 million people gained coverage.

Drug Coverage and Multiple Myeloma Care

Having access to prescription drug coverage boosts survival for patients with multiple myeloma, a new study has found. The Journal of Clinical Oncology reported that patients enrolled in Medicare Part D or other creditable coverage were more likely to be prescribed immunomodulatory drugs that led to longer survival.

Overall survival for these patients was 10% higher after 1 year and 6% higher at 3 years than patients without coverage.

Value-Based Cancer Care

To learn more about future perspectives on value-based care in oncology, join us for the upcoming session of the Institute for Value-Based Medicine, which will convene September 27 in New York City.

Andrew Pecora, MD, FACP, will moderate a panel discussion featuring a case study from Regional Cancer Care Associates, which operates in New Jersey, Connecticut, and Maryland. Allen Karp of Horizon Blue Cross Blue Shield New Jersey will offer a payer perspective.

Learn more and register.

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

Thanks for joining us.

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