Payers

Having a biosimilar on formulary makes it more likely the biosimilar will be adopted. Length of time a biosimilar is on market can impact how likely it is to be added to formulary.

The FDA approved the first high-concentration adalimumab biosimilar. A low-concentration version of the biosimilar, Hadlima, was already approved. Both versions will launch in July 2023.

Insurance reimbursement for teleophthalmology services is not consistent among populations and only recently received a boost due to flexibilities allowed during the pandemic, said Parisa Emami-Naeini, MD, MPH, assistant professor of ophthalmology at University of California, Davis, and vitreoretinal surgeon and uveitis specialist at UC Davis Eye Center.

The Institute for Value-Based Medicine series visits Texas Oncology in Austin.

More efforts need to be made to remove unconscious bias when implementing approved diabetes technologies into clinical practice for all patients, said Viral Shah, MD, an endocrinologist and scientist.

Policy observers and industry stakeholders debate the possible spillover effects of Medicare drug pricing reform in the employer-based insurance market; a California federal judge rules Walgreens could be held liable for not investigating suspicious orders of opioids in San Francisco; a blood test performed the day of a traumatic brain injury (TBI) can predict which patients may die and who may survive with a disability.

The ruling by the Supreme Court on 340B reimbursements was narrow, but it sets up a future reimbursement reduction by HHS that is even greater based on survey data, said Ted Okon, MBA, executive director, Community Oncology Alliance.

There are some similarities among various value-based payment programs for cancer care, but they are not identical, said Susan Escudier, MD, FACP, vice president, value-based care and quality programs, Texas Oncology.

New heart failure guidelines redefine stages of the disease to emphasize prevention, said Biykem Bozkurt, MD, PhD, but more must be done by payers to identify those at high risk.

HR 5376, or the Inflation Reduction Act, is most significant piece of legislation affecting federal health policy since the passage of the Affordable Care Act in 2010; for Medicare beneficiaries, it caps insulin at $35 a month and includes other pricing reforms.

Medicaid expansion was associated with substantial changes in Medicaid managed care plan composition, which may influence a plan’s performance on enrollee experience metrics.

Limiting access to non–vitamin K antagonist oral anticoagulants through step therapy and prior authorization may exacerbate current underuse of anticoagulants and increase the risk of stroke in patients with newly diagnosed atrial fibrillation.

The involvement of pharmacy benefit managers (PBMs) in 340B is the “colliding of 2 worlds,” said Ted Okon, MBA, executive director, Community Oncology Alliance.

Although there is a paucity of data of switching among biosimilars of the same reference product, the few studies published support the safety and effectiveness of transitioning patients from one biosimilar to another.

FAIR Health published the findings of their 15-year analysis of Lyme disease, including an increase in private insurance claim lines in rural and urban areas from 2007 to 2021.

Even though the Oncology Care Model (OCM) ended on June 30, 2022, there are some improvements that practices should continue implementing, said Susan Escudier, MD, FACP, vice president of value-based care and quality programs, Texas Oncology.

Senator Joe Manchin, D-West Virginia, ended his opposition to the Inflation Reduction Act of 2022, paving the way for reductions in some Affordable Care Act subsidies and action on drug pricing; AbbVie’s Allergan agreed to pay more than $2 billion in opioid settlements; a study found vitamin D supplements do not reduce bone fracture risk.

As part of the investigation into pharmacy benefit managers (PBMs), the Federal Trade Commission (FTC) should delve into how PBMs are impacting and fueling drug prices and set up guardrails to protect Americans, said Ted Okon, MBA, executive director, Community Oncology Alliance.

In retina surgery, obtaining prior authorization is an extra burden, and a delay in treatment for some of these patients could mean loss of vision, said Sabin Dang, MD, ophthalmologist with The Retina Institute.

Elaine Siegfried, MD, professor of pediatrics and dermatology, Saint Louis University Health Sciences Center, speaks on step edits and other barriers limiting access to biologic, topical, and other medications for the treatment of atopic dermatitis (AD).

Patients who experienced Clostridioides difficile infection had increased risks of mortality and hospital readmission, as well as greater length of stay and total hospital charges.

Stakeholders from Horizon Blue Cross Blue Shield of New Jersey discuss new ways to address management gaps for chronic behavioral health conditions, including a new integrated care model that puts community behavioral health providers in charge of overall care.

Until recently, ophthalmologists in the United States have had no experience with biosimilars, despite the availability of biosimilars for bevacizumab, which is commonly used off label for ophthalmic conditions.

While prior authorizations are put in place to ensure appropriate use of expensive therapies, they create a substantial burden for clinicians and patients, said Sabin Dang, MD, ophthalmologist with The Retina Institute.

Results looking at acceptance of minimal residual disease (MRD) status found that 60% of participants “would change at least one decision based on an MRD result,” and 54% would use both MRD status and disease risk to make decisions.

Although technology is allowing for earlier detection of eye conditions, lack of reimbursement and insurance coverage remain major barriers to widespread use, explained speakers at the American Society of Retina Specialists 40th Annual Scientific Meeting.

During a session at the American Society of Retina Specialists 40th Annual Scientific Meeting, speakers highlighted research into the opportunity cost of vitreoretinal surgery and the impact the pandemic had on retinal procedures and reimbursement in early 2020.