Payers

Nondrug therapies that might have been dismissed 30 years ago are now the sorts of treatments physicians are turning to instead of overused treatments like surgical procedures, opioids, and injections, said Daniel Clauw, MD, professor of anesthesiology, medicine (rheumatology), and psychiatry; director of translational research; and director of the Center for Chronic Pain and Fatigue Research.

Every week, The American Journal of Managed Care® recaps the top managed care news of the week, and you can now listen to it on our podcast, Managed Care Cast.

The evidence shows that chimeric antigen receptor (CAR) T-cell therapies are effective, but the price tags on these treatments are high and have raised concerns about how many patients will get treated. During a discussion at The American Journal of Managed Care®’s Patient-Centered Oncology Care® meeting, held Friday in Philadelphia, panelists outlined the efficacy of the 2 FDA-approved therapies, Medicare reimbursement for CAR T-cell therapies, and the pace of innovation in healthcare.

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.

A majority of patients with acute graft-versus-host disease (GVHD), but not all, have significant responses to the addition of ruxolitinib, said David Snyder, MD, associate chair of the Department of Hematology & Hematopoietic Cell Transplantation at City of Hope.

Approximately 4% of the total world population is affected by a rare disease at any given time, according to new research on 3585 rare diseases.

This week, the top managed care stories included a report from the FDA considering how to avoid drug shortages; a white paper finds rising comfort with telehealth even as use of digital health tools stagnates; data show a spike in the number of uninsured children.

Prithviraj Bose, MD, of MD Anderson Cancer Center discusses the risk of patients being treated with JAK inhibitors developing non-Hodgkin lymphoma.

By using the available evidence, data, and facts surrounding healthcare spending, we can begin conversations on necessary innovations, said Ceci Connolly, BA, president and chief executive officer of Alliance of Community Health Plans.

Broad population-based genomic screening has the potential to improve patient care by detecting genetic causes of disease before they occur; however, the economics behind this approach have not fully been validated, according to a session on the clinical and economic utility of whole-genome sequencing at the AMCP Nexus 2019 meeting.

Although the number of people with nonalcoholic fatty liver disease, which progresses to nonalcoholic steatohepatitis (NASH), is growing, the health system is still trying to get a handle on which patients to target and how to identify them before the first treatments come to market, explained panelists during a session at AMCP Nexus 2019.

Increased competition is making its way into the specialty drug market, affecting orphan conditions, cancer types, and even common specialty conditions, which is presenting some cost savings opportunities, explained Aimee Tharaldson, PharmD, senior clinical consultant for emerging therapeutics at Express Scripts, who presented on the specialty pharmaceutical pipeline during her regular session at AMCP Nexus 2019.

Value needs to be considered early in the development life cycle of a therapy and should be continued throughout, even into the postlaunch space using real-world studies, according to a presentation on value-based services and their life cycles at the AMCP Nexus 2019 meeting.

New high-cost therapies require new financing mechanisms, but the challenge is coming to an agreement on what should be considered in these new payment models, said Jane Barlow, MD, MPH, MBA, executive vice president and chief clinical officer for Real Endpoints.

As the number of high-cost orphan drugs and gene and cell therapies continues to grow, there will be a greater need for alternative payment models to help figure out the best way to pay for these treatments.

As the number of expedited FDA approvals for cancer drugs that are based on surrogate end points increases, so does the need for new ways to uncover efficacy and safety data to justify the costs associated with these treatments. With the growth of data innovations and collaborations, the answer might be found in real-world evidence.

Use of digital health tools appears to have leveled off in 2019, according to one study, but another finds that use of telehealth is poised to grow considerably.

Accountable care organizations (ACOs) face a learning curve before they start achieving savings. David Carmouche, MD, president of the Ochsner Health Network and executive director of the Ochsner Accountable Care Network, explains how the Ochsner ACO was able to find success and how other ACOs can get over the learning curve to achieve savings.

Collaboration with RAFI-USA will benefit shoppers in rural areas.

Unlike many other cancer rates that have been on the decline, liver cancer rates for new liver and intrahepatic bile duct cancer cases have been rising. This October, which is Liver Cancer Awareness Month, Global Liver Institute is joining with more than 30 other leading health and medical organizations, to issue a global call-to-action to increase the 5-year survival rates for patients with liver cancer from 18% to 36% by 2030.

Every week, The American Journal of Managed Care® recaps the top managed care news of the week, and you can now listen to it on our podcast, Managed Care Cast.

Less than half of Medicare patients newly diagnosed with blood cancer are receiving treatment for their cancer shortly after diagnosis, which may be attributed to the high cost burden they face, according to a new report from Milliman commissioned by The Leukemia & Lymphoma Society.

This week, the top managed care news included the average Affordable Care Act premiums falling 4%; the FDA approving a triple combination treatment for cystic fibrosis; House Republicans releasing part 1 of their healthcare plan.

As costs for cancer care continue to rise, Pontchartrain Cancer Center does benefit and cost analyses for all patients before they start therapy and also takes into account any social needs they might have, said Kathy W. Oubre, MS, chief operating officer at Pontchartrain Cancer Center.

Employers did not intentionally set out to address social determinants of health, but the programs they were implementing were doing so, said Michael Thompson, president and chief executive officer of the National Alliance of Healthcare Purchaser Coalitions.

While freestanding emergency departments (EDs) can reduce wait times and reduce the burden on overcrowded EDs, they increase utilization of emergency care and local market spending.

A Colorado-based company, SonderMind, seeks to take on the financial risk associated with reimbursement for mental healthcare so that therapists will be more willing to see patients using their insurance coverage.

The change to the public charge rule has had a negative impact on immigrant patients, who are disenrolling or declining to enroll in Medicaid and are delaying or avoiding care, according to a survey of community health centers.

Mental health care is an area of focus for the National Alliance of Healthcare Purchaser Coalitions, because this care is getting worse despite there being more acceptance regarding the need for improved mental health, said Michael Thompson, president and chief executive officer of the National Alliance of Healthcare Purchaser Coalitions.

More practices than expected seem to be interested in staying in the Oncology Care Model (OCM) and taking on downside risk, said Mike Fazio, senior vice president of client services, Archway Health.