Insurance

Industry experts discussed the big issues facing accountable care organizations (ACO) at the Brookings Institute's event, The State of Accountable Care: Evidence to Date and Next Steps, held Monday in Washington, DC.

Attendees at the ACO and Emerging Healthcare Delivery Coalition meeting held October 16-17, 2014, in Miami, Fla., gained insights to help physicians and accountable care organizations achieve the "Triple Aim" of better population health, greater patient satisfaction, and lower costs. This initiative of The American Journal of Managed Care has now attracted more than 120 members.

Myriad Genetics, Inc., announced today that the Medicare Administrative Contractor (MAC) that has jurisdiction over most molecular diagnostic tests has issued its draft notice on how Medicare will provide reimbursement for Prolaris, a test that Myriad has developed to guide treatment decisions in prostate cancer.

The Centers for Medicare and Medicaid Services wants hospitals to find ways to keep patients from returning to the hospital, and the agency has created rewards and punishments in pursuit of this goal. A study in The American Journal of Managed Care is just one of a pair of recent clinical trials that finds readmissions may be beyond some hospitals' control, and policymakers might need to rethink their approach.

Quality of care varies according to the compensation methods used in primary care, but the relationship between compensation methods and preventable hospital admissions is inconsistent.

Accountable Care Organizations participating in the Medicare Shared Savings Program will have access to a new initiative that will support care coordination across the country, according to CMS. Up to $114 million in upfront investments will be made available.

The quality bonus payments tied to CMS' star ratings makes it critical that health plans receive a 4 or better, Jonathan Harding, MD, chief medical officer of the Senior Products Division at Tufts Health Plan, said at the America's Health Insurance Plan's National Conferences on Medicare and Medicaid, and Dual Eligibles Summit in Washington, DC, from September 28 to October 2.

Ohio is the latest state to experience a rough transition to managed care in its Medicaid program, according to weekend reports. Delayed payments and service disruptions to fragile patients are among the complaints. Kentucky had a similar bumpy start when it changed to Medicaid managed care in 2011, and Kansas has had many problems recently.

For the third year in a row, Medicare Part B monthly premiums and deductibles will remain unchanged at $104.90 and $147, respectively, according to HHS Secretary Sylvia Burwell.

How a health plan performs in the CMS star ratings to going to have a bigger impact on their finances in the coming years, Snezana Mahon, PharmD, senior director of Medicare solutions at Express Scripts, said.

Self-reported health measures embedded in a Medicaid application can comprise a predictive model identifying new and returning enrollees at risk of high healthcare utilization.

Payroll audits to ensure proper staffing and better tracking of the use of antipsychotic medications are just 2 new items that the Centers for Medicare and Medicaid (CMS) will add to its list of quality measures for nursing homes starting in January, the agency that oversees all Medicare spending announced Monday. The changes are due to passage of the Improving Medicare Post-Acute Care Transformation Act (IMPACT) which President Obama signed Monday. Some of the changes will bring managed care concepts to the home health sector, where regulations have not been updated in 25 years

Peter B. Bach, MD, MAPP, Memorial Sloan Kettering Cancer Center, writes in the Journal of the American Medical Association that cancer drugs could be charged different prices by indication, since the value for patients varies. His article appeared days before an appearance on 60 Minutes to discuss the high price of cancer drugs.

During the third year of the Hospital Readmission Reduction Program, CMS will penalize more hospitals than it did during the second and third years of the program; however, the overall readmission rate for Medicare beneficiaries is down.

Health plans, providers, and consumers have to collaborate in order to bring value, Craig Thiele, MD, chief medical officer at CareSource, said at the America's Health Insurance Plans' National Conferences on Medicare and Medicaid, and Dual Eligibles Summit.

The most recent Medicare Advantage and Part D program audits revealed that oversight of formulary administration is an area that health plans continue to struggle with, Sarah J. Lorance, vice president of Medicare Compliance at WellPoint, said at America's Health Insurance Plans' National Conference on Medicare and Medicaid and Dual Eligibles Summit in Washington, DC.

Plans designed specifically for disabled dual-eligible Medicare and Medicaid beneficiaries are not necessarily enough to reduce use of costly services, according to a new report from the Government Accountability Office.

Both Medicare and commercial insurers have raised the bar for molecular diagnostic companies, requiring them to show clinical utility to receive reimbursement for cellular tests designed to guide treatment in cancer, rheumatoid arthritis, and other diseases. An important new article in The American Journal of Managed Care reviews cases from a top Medicare contractor and outlines how to build the evidence to meet today's standards.

The Affordable Care Act will save hospitals a projected $5.7 billion in uncompensated care this year, according to a report released by HHS. Roughly three-quarters of those savings are coming from Medicaid expansion states.

So far, the recent failure of a high-profile bundled payment pilot in California has not slowed enthusiasm for the concept from CMS.

Since it appeared last week, the editorial in the September issue of The American Journal of Managed Care, "Is All ‘Skin the Game' Fair Game? The Problem With ‘Non-Preferred' Generics," has received comment in The New York Times, ProPublica, US News and World Report, and Mother Jones, among others. Commentators note that what Gerry Oster, PhD, and Co-Editor-in-Chief, A. Mark Fendrick, MD, uncovered in their brief survey of health plans is not just disturbing but possibly violates the Affordable Care Act's prohibition against discrimination based on pre-existing conditions.

Driven by a consolidation of offerings, the number of Part D prescription drug plans will decrease by 14% in 2015. While monthly premiums will decrease overall by 2%, there will be large premium variations.

The authors comment on the growth of drug plans with tiers for "non-preferred" generics, and argue that most are inconsistent with established principles of formulary design.

Out-of-plan medication use accounted for a small share of diabetes, hypertension, and hyperlipidemia prescriptions filled by Medicare Part D beneficiaries.

Putting various branded drugs in "non-preferred" tiers and charging higher copays for them has been used for a number of years to steer consumers to use less costly medicines by giving them "skin in the game." But authors writing for The American Journal of Managed Care are alarmed by the policies of some insurers that now have designated entire classes of widely used generic drugs "non-preferred," leaving many patients without any low-cost treatment options for their diseases.

During the second year of the program, Medicare accountable care organizations reported improvements in nearly all of the quality and patient experience measures, according to data reported by CMS.

A study published in the Annals of Internal Medicine, the result of a collaboration between CVS Caremark and scientists at the Brigham and Women's Hospital and the Harvard Medical School, compared patient adherence to brand name versus generic statins.