Managed Care Cast

Accountable care organizations are incentivized to reduce spending and improve quality of care. One way they have tried to do achieve these goals is by establishing control over a patient’s full continuum of care by minimizing the care patients receive from other providers outside of the ACO, including specialists. Michael Barnett, MD, and J. Michael McWilliams, MD, PhD, have a paper in the May issue of The American Journal of Managed Care® on leakage of specialty care among ACOs and the changes in specialty care leakage and use associated with the Medicare Shared Savings Program. Read the paper: http://www.ajmc.com/journals/issue/2018/2018-vol24-n5/changes-in-specialty-care-use-and-leakage-in-medicare-accountable-care-organizations

Patients who get care at a hospital often receive bills that are bigger than they were expecting. In the case of Medicare, this can happen when a beneficiary receives care at a hospital for several days but was never formally admitted to the hospital. The result is higher out-of-pocket expenses and fewer Medicare benefits—the biggest being the qualification of a nursing home stay after being discharged from a hospital. While hospitals must now inform Medicare recipients when they are being held under observation status, the use of observation still places an undue burden on seniors. Andria Jacobs, chief operating officer for PCG Software, discusses the impact of being held in observation, what CMS has done to try to alleviate the situation, and what else needs to be done. Read Andria's past articles: http://www.ajmc.com/contributor/andria-jacobs-rn-ms-cen-cphq

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. This week, the top managed care stories included a report that insurance coverage gains are reversing; a deal to lower the cost of Praluent for Express Scripts members; findings that synthetic opioids are playing a bigger role in overdose deaths. Increases in Insurance Coverage Rates From ACA Beginning to Reverse: www.ajmc.com/focus-of-the-week/increases-in-insurance-coverage-rates-from-aca-beginning-to-reverse Sanofi, Regeneron to Cut Praluent Prices Under Exclusive Express Scripts Deal That Ends Prior Approval Delays: www.ajmc.com/newsroom/sanofi-regeneron-to-cut-praluent-prices-under-exclusive-express-scripts-deal-that-ends-prior-approval-delays Dr Jay Edelberg on Safety, Efficacy of Praluent and Remaining Payment Challenges: www.ajmc.com/conferences/aha-2017/dr-jay-edelberg-on-safety-efficacy-of-praluent-and-remaining-payment-challenges Synthetic

Low-Value Services: Their Impact and Challenges With Addressing Them by Managed Care Cast

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. This week, the top managed care stories included an announcement from CMS of creating direct provider contracting, plus a broad set of proposed rules for health information technology; new recommendations to improve postpartum care; a look at future competition among specialty drugs. Read more about the stories in this podcast: CMS: "Meaningful Use" Is Out, "Interoperability" Is In: www.ajmc.com/newsroom/cms-meaningful-use-is-out-interoperability-is-in Humana Launches Bundled Payment Model to Improve Maternity Outcomes and Cost: www.ajmc.com/newsroom/humana-launches-bundled-payment-model-to-improve-maternity-outcomes-and-cost What We're Reading: VA Pick's Hearing Delayed; Hospital Profits Fall; Re-Imagining Postpartum Care: www.ajmc.com/newsroom/what-were-reading-va-picks-hearing-delayed-hospital-profits-fall-reimagining-postpartum-care ACOG Annual C

At the beginning of the year, The American Journal of Managed Care® convened a panel of experts in infectious disease and managed care to discuss management of HIV, including the need for individualized care the role for newer treatments options. Here, we provide some of that conversation. Watch the full discussion: Special Considerations in HIV Management: www.ajmc.com/peer-exchange/special-considerations-in-hiv-management/

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. This week, the top managed care stories included a new bill in Congress to tackle the opioid epidemic; an analysis that warns against including drug costs in bundled payment models; the FDA commissioner shares ideas to improve innovation and access to next-generation sequencing. Read more about the stories in this podcast: Congress, Medical Societies Move on Ways to Attack Opioid Problem: www.ajmc.com/newsroom/congress-medical-societies-move-on-ways-to-attack-opioid-problem Bundled Payments That Include Drug Costs Would Penalize Practices Based on Patient Mix: www.ajmc.com/newsroom/bundled-payments-that-include-drug-costs-would-penalize-practices-based-on-patient-mix FDA Finalizes Guidances to Accelerate Development of Next-Generation Sequencing Tests: www.ajmc.com/newsroom/fda-finalizes-guidances-to-accelerate-development-of-next-generation-sequenci

Current policies being employed to limit spending can have serious consequences for patients. In the April issue of The American Journal of Managed Care, A. Mark Fendrick, MD, co-authored a paper that examined the relationship between consumer cost sharing for branded antidepressants and the initiation of branded therapy among patients who were filling a prescription for a generic medication to treat major depressive disorder. Read the paper: Cost Sharing and Branded Antidepressant Initiation Among Patients Treated With Generics: www.ajmc.com/journals/issue/2018/2018-vol24-n4/cost-sharing-and-branded-antidepressant-initiation-among-patients-treated-with-generics

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. This week, the top managed care stories included President Donald Trump signing an executive order requiring the poor to get jobs or lose food and healthcare benefits; a CMS report found ethnic, racial, and gender disparities in Medicare Advantage plans; CDC highlighted the impact of HIV on America's youth. Read more about the stories in this podcast: What We're Reading: Trump Signs Executive Order; VA Staffing Crisis; Texas Hospital Firm Draws Scrutiny: www.ajmc.com/newsroom/what-were-reading-trump-signs-executive-order-va-staffing-crisis-texas-hospital-firm-draws-scrutiny- CMS Creates New ACA Penalty Mandate Exemptions, Including Opposition to Abortion: www.ajmc.com/newsroom/cms-creates-new-aca-penalty-mandate-exemptions-including-opposition-to-abortion CMS Report Details Extent of Medicare Advantage Racial, Gender Disparities: www.ajmc.com/newsroo

With the cost of healthcare rising, consumers are being asked to shoulder more of the financial burden and make more cost-conscious decisions regarding their healthcare. One method to do this is through the use of consumer-directed health plans, which are high-deductible health plans coupled with a health savings account or a health reimbursement arrangement. Neeraj Sood, PhD, co-authored a paper in the April issue of The American Journal of Managed Care (AJMC) evaluating the impact of enrollment in consumer-directed health plans on financial burden associated with healthcare utilization. Read Sood's paper “Financial Burden of Healthcare Utilization in Consumer-Directed Health Plans” in the April issue of AJMC: http://www.ajmc.com/journals/issue/2018/2018-vol24-n4/financial-burden-of-healthcare-utilization-in-consumer-directed-health-plans

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. This week, the top managed care news included final numbers for 2018 enrollment in Affordable Care Act plans; an increase in Medicare Advantage payments; National Public Health Week highlighted the importance of community relationships in improving health. Read more about the stories in this podcast: What We're Reading: 2018 ACA Enrollment; Spread of Rare Superbug; Off-the-Shelf CAR T Therapies: www.ajmc.com/newsroom/what-were-reading-2018-aca-enrollment-spread-of-rare-superbug-offtheshelf-car-t-therapies CMS Final Rule Lowers Maximum Co-Payment Amount for Biosimilars: www.centerforbiosimilars.com/news/cms-final-rule-lowers-maximum-copayment-amount-for-biosimilars CMS Raises Medicare Advantage Payments, Tweaks Opioid Language for Patients With Pain: www.ajmc.com/newsroom/cms-raises-medicare-advantage-payments-tweaks-opioid-language-for-pain-patients

Locations, Types, and Characteristics of Data Breaches in Hospitals by Managed Care Cast

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. This week, the top managed care stories included another insurer announcing it would pass on drug rebates to consumers; FDA approved a new continuous glucose monitor and created a new medical device class; new guidelines address how to treat people with both HIV and cancer. Read more about the stories in this podcast: What We're Reading: Accidental Medicaid Enrollment; Cracking Down on Opioids; Passing on Drug Rebates: www.ajmc.com/newsroom/what-were-reading-accidental-medicaid-enrollment-cracking-down-on-opioids-passing-on-drug-rebatesUnitedHealthcare to Pass Drug Company Rebates Back to Consumers: www.ajmc.com/newsroom/unitedhealthcare-to-pass-drug-company-rebates-back-to-consumers Out-of-Pocket Costs for Insulin Are a Problem. Litigants in Case Disagree on Who Is at Fault: www.ajmc.com/newsroom/out-of-pocket-costs-for-insulin-are-a-problem-litigan

As the country searches a new way to address cost of care, value-based insurance design (VBID), is gaining traction as one way of encouraging the use of high-value services and discouraging the use of low-value services. VBID would give patients access to treatments and services with high clinical value at reduced or no cost sharing. Currently, health plans tend to value all treatments and services as equal in clinical value to all patients, even though this is not the reality. On March 14, the University of Michigan’s V-BID Center hosted its annual VBID Summit with discussions on aligning around value, how public payers are adopting VBID principles, addressing the use of low-value care services, and creating a smarter high-deductible health plan. Read coverage of the panels from the V-BID Summit: The Challenge of Addressing Low-Value Care Once It's Identified: www.ajmc.com/conferences/v-bid-summit-2018/the-challenge-of-addressing-lowvalue-care-once-its-identified How Public Payers Are Adopting VBID Princip

On March 14, advocates for community cancer centers took to Capitol Hill to speak with legislators and advocate for the issues important to them and their patients. At the Association of Community Cancer Centers' (ACCC) 44th Annual Meeting and Cancer Business Summit, Blaire Burnett of ACCC, George Spurlock of Southern Cancer Center, and Randall Oyer, MD, of Lancaster General Health, discussed their experiences with Capitol Hill Day and what issues they discussed with legislators. For coverage of sessions and interviews with speakers from the ACCC 44th Annual Meeting and Cancer Business Summit, visit our conference page: http://www.ajmc.com/conferences/accc-2018.

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. This week, the top managed care stories included changes to the Next Generation ACO Model caused 7 accountable care organizations to leave the model; a report highlights how quickly hospital acqusition of physician practices is occurring; CMS finalizes coverage for Next-Generation Sequencing tests. Read more about the stories in this podcast: Seven ACOs Exit Next Generation Model, Blaming CMS for "Unilateral" Changes: www.ajmc.com/newsroom/seven-acos-exit-next-generation-model-blaming-cms-for-unilateral-changes Accountable Care Delivery Congress: www.ajmc.com/acdcongress Hospital Acquisition of Independent Physician Practices Continues to Increase: www.ajmc.com/focus-of-the-week/hospital-acquisition-of-independent-physician-practices-continues-to-increase First-of-a-Kind Companion Test for Cancer Gene Profiling Gets FDA Approval: www.ajmc.com/newsroo

As the US healthcare system searches for a way to address the poor health and high healthcare costs of American, one concept has risen to the top and received a lot of attention: social determinants of health. These are the conditions in which people are born, live, and work that impact their health. And they are mostly responsible for health inequities. There are a number of conditions that are considered social determinants of health, including access to educational, economic, and job opportunities; transportation options; public safety; and housing. In this podcast, we focus on the issue of housing, and how communities are working to get people into housing so their health can improve. Learn more about social determinants of health: Program Nets Substantial Savings by Housing Homeless Individuals With Health Issues http://www.ajmc.com/focus-of-the-week/program-nets-substantial-savings-by-housing-homeless-individuals-with-health-issues Developing State-Level Programs for Care of Complex Populations www

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. This week, the top managed care stories included Sanofi offering a deal to payers for its cholesterol drug; a “right-to-try” bill is defeated in the House; and a forum of oncology pharmacists discusses “health insurance” versus “healthcare.” Read more about the stories in this podcast: With ODYSSEY Results in Hand, Talks With Payers Begin to Jump Start Praluent Sales: www.ajmc.com/conferences/acc-2018/with-odyssey-results-in-hand-talks-with-payers-begin-to-jump-start-praluent-sales "Right-to-Try" Legislation Defeated in House Amid Doubts About Its Necessity: www.ajmc.com/newsroom/right-to-try-legislation-headed-for-a-vote-as-doubts-about-its-necessity-remain Coverage of the American College of Cardiology’s 67th Annual Scientific Session & Expo: www.ajmc.com/conferences/acc-2018 Rep. Doug Collins: Providing Healthcare vs Health Insurance: www.ajmc.com

As hospitals are increasingly held accountable for what happens outside the hospital walls, they need access to better claims data. In a recent study published in November issue of The American Journal of Managed Care®, researchers with the Michigan Value Collaborative found that it is possible to derive episode-level utilization from claims data and it provides a level of postdischarge care precision that is superior to medical records that hospitals have access to. Read the study: Validation of a Claims-Based Algorithm to Characterize Episodes of Care: www.ajmc.com/journals/issue/2017/2017-vol23-n11/validation-of-a-claimsbased-algorithm-to-characterize-episodes-of-care

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. This week, the top managed care stories included Cigna's deal to buy Express Scripts; Seema Verma, Alex Azar, and Scott Gottlieb, MD, made the rounds at health conferences; an analysis finds FDA's accelerated approval pathway has been a success with hematology and oncology drugs. Read more about the stories in this podcast: Healthcare Mergers Continue With Deal for Cigna to Acquire Express Scripts: www.ajmc.com/newsroom/cigna-to-acquire-express-scripts-in-67-billion-deal What We're Reading: Verma on Health Data; More Medicaid Work Requirements; NJ Individual Mandate: www.ajmc.com/newsroom/what-were-reading-verma-on-health-data-more-medicaid-work-requirements-nj-individual-mandate Azar Tells Insurance Industry Patients Must Be in Charge of Their Own Data: www.ajmc.com/newsroom/azar-tells-insurance-industry-patients-must-be-in-charge-of-their-own-data