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Episode 3 - Managed Care Concerns and Treatment Accessibility
During this segment, the panelists share insights about clinical practice guidelines such as those released by the National Comprehensive Cancer Network (NCCN) and Centers for Medicare & Medicaid Services (CMS) and discuss their impact on managed care.
The panelists explain that as organizations such as the NCCN and CMS continue to enforce stricter requirements with more paper work than previously, when payers try to adjudicate the quality of the evidence and look to a panel of experts to help them negotiate expenses, it impacts managed care.
Michael Kolodziej, MD, suggests that currently the payers are the gatekeepers when managing this information. However, a shift to providers becoming the gatekeepers is under way.
Jeffrey Weber, MD, PhD, is concerned that this shift will burden providers. However, Dr Kolodziej and Daniel J. George, MD, disagree, and explain that the forms that are required to be filled out are simple and brief.
Dr George explains that the burden occurs when coverage for expensive cancer immunotherapy agents is denied. At this point, a peer-to-peer process is requested, in which a healthcare professional discusses the case with another healthcare professional. The peer-to-peer process includes additional reviews and takes a considerable amount of time.
New Research Challenges Assumptions About Hospital-Physician Integration, Medicare Patient Mix
April 22nd 2025On this episode of Managed Care Cast, Brady Post, PhD, lead author of a study published in the April 2025 issue of The American Journal of Managed Care®, challenges the claim that hospital-employed physicians serve a more complex patient mix.
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Specialty Drug Users to Gain Relief Under Medicare Reforms
May 16th 2025A new analysis looked at estimated out-of-pocket costs for etanercept, ustekinumab, and ibrutinib, specialty drugs that often represent a significant cost burden for Medicare Part D beneficiaries and which were selected for 2026 drug price negotiation under the Inflation Reduction Act.
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Varied Access: The Pharmacogenetic Testing Coverage Divide
February 18th 2025On this episode of Managed Care Cast, we speak with the author of a study published in the February 2025 issue of The American Journal of Managed Care® to uncover significant differences in coverage decisions for pharmacogenetic tests across major US health insurers.
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Navigation and Clinician Payment Investments Enhance Colorectal Cancer Screening Benefits
May 15th 2025Investing in patient navigation and clinician incentives ensures colorectal cancer screening completion, improves early detection, reduces disparities, achieves cost savings, and advances population health for all stakeholders.
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