Health Care Cost

The challenges of complying with payer mandates in biosimilars were discussed in a webinar sponsored by The American Journal of Managed Care® and The Center for Biosimilars®.

Given the constraints prevalent post-COVID-19, Dr Mark Fendrick, director of the University of Michigan Center for Value-Based Insurance Design, stresses that it is now more important than ever for the health care industry to prioritize payment reform, value-based benefit design, and novel policy initiatives.

Despite concerns, legislation to cap out-of-pocket payments for specialty drugs has not been shown to shift costs to health plans, thereby increasing insurance premiums, according to a study published in New England Journal of Medicine.

The coronavirus disease 2019 (COVID-19) vaccines that are leading the pack are utilizing a new vaccine technology that has never been approved for human use by the FDA. As a result, there are a lot of unknowns.

The ruling reversed a lower court ruling regarding the drug discount program for hospitals that serve patients covered by Medicaid.

End-stage renal disease has long been one of the most expensive and debilitating conditions that affects Medicare beneficiaries. Not only does dialysis cost $90,000 a year—those awaiting a kidney transplant automatically qualify for Medicare—but the need to travel to a dialysis center multiple times a week disrupts employment and home life.

Oncology practices could use more time to become accustomed to 2-sided risk even without a global pandemic, but the current crisis makes the need more urgent, say payment reform leaders at the Community Oncology Alliance virtual conference.

At the 2020 Community Oncology Conference, hosted by the Community Oncology Alliance, Howard "Skip" Burris III, MD, FACP, FASCO, president, chief medical officer, and executive director of drug development for Sarah Cannon Research Institute, will discuss "The Now and Future of Clinical Trials in the Community Oncology Setting." The American Journal of Managed Care® recently spoke with Burris, who is wrapping up his term as president of the American Society of Clinical Oncology, about how the coronavirus disease 2019 pandemic is affecting clinical trials as well as other aspects of the future of patient care in community oncology settings.

As Kidney Week closed, nephrologists gathered to hear policy updates and information about forthcoming payment models from CMS and seemed pleased with what they heard.

This article provides an overview of the impact of specialty care and the opportunity for it to leapfrog primary care as a lead focus for accountable care.

This paper presents a method to characterize policy implementation across states to enable more nuanced impact assessments of federal healthcare delivery system and payment reforms.

Physician groups have begun designing alternative payment models for their own specialties, proposing that CMS include financial risk, funding for new technologies, and legal waivers.

There are less surprises in the results for performance period 4 of the Oncology Care Model, and practices seem to be mostly happier with how they’ve done, said Mike Fazio, senior vice president of client services, Archway Health.

The cost of radiation oncology services has typically been a small part of the Medicare and Medicaid budget, but with more patients having complex radiation treatments, it is becoming more important to have alternative payment models in the space, said Shalom Kalnicki, MD, FASTRO, FACRO, professor and chairman, radiation oncology, Montefiore Einstein Center for Cancer Care and Albert Einstein College of Medicine.

Practices should make deliberate choices when choosing to participate in multiple payment reform models and should not just participate in something because it is the newest model, said Travis Broome, vice president of policy at Aledade.

Depending on how ready accountable care organizations (ACOs) are to move to risk probably affects how they view CMS’ decision to transition the Medicare Shared Savings Program (MSSP) to Pathways to Success, said Travis Broome, vice president of policy at Aledade.

The healthcare system has a long way to go to make voluntary payment models more attractive before it can consider making payment models mandatory, said Travis Broome, vice president of policy at Aledade.

Bringing together different stakeholders in healthcare to share the challenges they see and their own understanding of how to fix the problem can help make impossible things happen and bring change to the healthcare system, said Elizabeth Mitchell, president and chief executive officer, Pacific Business Group on Health.

Currently, the number of patients who are actually utilizing precision cancer care treatments is small, but it is growing fast. As that happens, physicians will need to get comfortable with ordering the right tests, explained Clynt Taylor, chief executive officer of Intervention Insights, and Lee Newcomer, MD, formerly of UnitedHealth Group.

Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs) cover more than 32 million lives and have been found to save money and improve quality in past research, but a new study in Annals of Internal Medicine is calling their success into question.

The American Journal of Managed Care® sat down with David Smith, the executive director of the Medicaid Transformation Project, to get an update about the integration challenges health systems are facing, including system issues, infrastructure issues, coding and payment issues, and more.

A study of readmission rates by primary care providers (PCPs) finds a lack of variation and calls into question implementing pay-for-performance programs that incentivize or penalize PCPs for readmissions.

Humana has expanded its focus to the social determinants of health because issues like food insecurity and lack of transportation impact outcomes even if patients are getting the best medical care, said Bryan Loy, MD, physician lead, oncology, laboratory, and personalized medicine, Humana.

Even though Northwestern Medicine is projected to sustain a loss in the new Bundled Payments for Care Improvement Advanced, it plans to participate because doing so will position Northwestern Medicine as best possible to manage future challenges in episodes of care.

The advantage of having mandatory models is it enables you to get participation broadly across the community and it allows you to design the bundle in a way that’s not so intent on encouraging participation. If you have voluntary participation you are somewhat limited as to how you could design the bundle, because if you design it too aggressively no one will participate, explained Michael E. Chernew, PhD, the Leonard D. Schaeffer Professor of Health Care Policy; director of the Healthcare Markets and Regulation Lab in the Department of Health Care Policy at Harvard Medical School; and co-editor-in-chief of The American Journal of Managed Care®.