Payers

The Medical Group Management Association offers an analysis of pending legislation that could help health care practices better serve patients.

Half of the surveyed adults reported difficulty affording their health care, and a large proportion said they delayed or avoided care or medication because they couldn’t afford it, often leading to their health problems worsening.

Community oncology practices are witnessing a new dynamic in which more Medicare-eligible patients are still covered by commercial insurance, according to speakers at the Community Oncology Alliance Payer Exchange Summit, held October 23-24, 2023.

Clinical-grade, expert-supported natural language processing (NLP) is valuable to payers and providers when exchanging patient information through continuity-of-care documents.

Enfortumab vedotin plus pembrolizumab not only beat chemotherapy in the first-line setting for locally advanced metastatic urothelial cancer for the first time in decades, but it nearly doubled progression-free survival and overall survival vs chemotherapy.

Results of the monarchE study showed patients with hormone receptor–positive (HR+), HER2-negative (HER2–) high-risk, early breast cancer had greater benefit after 5 years when receiving adjuvant abemaciclib plus endocrine therapy vs endocrine therapy alone.

A 5-year randomized trial showed that the Million Hearts Model, which paid health care organizations to monitor and reduce cardiovascular disease (CVD) risk, was effective in reducing first-time heart attacks and strokes without associated increases in Medicare spending.

To ensure patients are getting timely access to their treatments, there needs to be better collaboration between payers and providers, said Christine Pfaff, RPh, senior regional director of operations, American Oncology Network.

Biosimilars are becoming more common as more launch on the market in the United States, but patient and provider education can help speed uptake of these products, explained Bincy Abraham, MD, Houston Methodist – Weill Cornell.

Lower-sodium oxybate (LXB) and sodium oxybate (SXB) were proven equally effective for cataplexy and excessive daytime sleepiness (EDS), despite LXB having 92% less sodium.

Cigna will pay $172 million to resolve allegations that it submitted inaccurate diagnosis codes for Medicare Advantage plan enrollees in order to increase payments from Medicare.

Providers have to know how to manage patients who are hesitant to switch to a biosimilar and payers who have specific preferences about which biosimilar to use.

The cohort study focused on annual incidence, prevalence, and mortality linked to a number of cardiovascular conditions between 2015 and 2019.

Drug maker payments to ophthalmologists were associated with the choice of higher-cost therapies for age-related macular degeneration (AMD) that could increase Medicare costs, but biosimilars could help.

Faced with new government regulations, Medicare Advantage (MA) organizations should be utilizing technology to increase the accuracy of their coding, mitigate their risk, and ensure appropriate care for members.

A survey of gastroenterologists, dermatologists, and rheumatologists found Amjevita had the most recognition, followed by Cyltezo, the only interchangeable biosimilar on the US market.

The AHEAD Model will operate for 11 years and aim to shift health care to community-based settings.

The frequency with which 7 of the largest Medicare Advantage plans impose step therapy protocols in their Part B drug coverage decisions varies substantially.

Insomnia, along with other sleep disorders, were found to negatively impact workplace productivity.

Enrollment in managed care among Medicaid enrollees presents challenges to classifying Medicaid coverage in cancer registries.

The playbook includes resources for purchasers to help in their dealings with pharmacy benefit managers (PBMs), including best practice checklists, sample questionnaires for choosing consultants, and recommendations for contracting language.

The Medicare Shared Savings Program (MSSP) generated its second highest annual savings since the program began more than a decade ago.

Biosimilars can improve access to treatment for patients who might not have been able to access biologics previously, explained Laura Wingate, executive vice president, Education, Support, & Advocacy, Crohn's & Colitis Foundation.

The Biden administration has released the first 10 drugs subject to price negotiation with Medicare under the Inflation Reduction Act (IRA), and among those chosen were Stelara (ustekinumab) and Enbrel (etanercept), both of which will face biosimilar competition within the next decade.

Physicians have been facing increasing workloads making it difficult to practice medicine as they were trained, but an accountable care organization might provide an opportunity for real change to deliver high-value, compassionate care.

COVID-19 hospital visits by adolescents nearly doubled; government to release list of drugs Medicare will be able to negotiate prices for; Rite Aid gears up for bankruptcy while facing lawsuits over alleged opioid involvement.

The Biden administration is expected to unveil the first 10 drugs identified for drug price negotiations Tuesday; American nursing homes are disappearing; gender-affirming surgeries tripled in the United States between 2016-2019.

In 2023, the United States was in the midst of the largest drug shortage in a decade, including lifesaving platinum-based medications to treat a variety of cancers.