Payers

New high-cost therapies require new financing mechanisms, but the challenge is coming to an agreement on what should be considered in these new payment models, said Jane Barlow, MD, MPH, MBA, executive vice president and chief clinical officer for Real Endpoints.

As the number of high-cost orphan drugs and gene and cell therapies continues to grow, there will be a greater need for alternative payment models to help figure out the best way to pay for these treatments.

As the number of expedited FDA approvals for cancer drugs that are based on surrogate end points increases, so does the need for new ways to uncover efficacy and safety data to justify the costs associated with these treatments. With the growth of data innovations and collaborations, the answer might be found in real-world evidence.

Use of digital health tools appears to have leveled off in 2019, according to one study, but another finds that use of telehealth is poised to grow considerably.

Accountable care organizations (ACOs) face a learning curve before they start achieving savings. David Carmouche, MD, president of the Ochsner Health Network and executive director of the Ochsner Accountable Care Network, explains how the Ochsner ACO was able to find success and how other ACOs can get over the learning curve to achieve savings.

Collaboration with RAFI-USA will benefit shoppers in rural areas.

Unlike many other cancer rates that have been on the decline, liver cancer rates for new liver and intrahepatic bile duct cancer cases have been rising. This October, which is Liver Cancer Awareness Month, Global Liver Institute is joining with more than 30 other leading health and medical organizations, to issue a global call-to-action to increase the 5-year survival rates for patients with liver cancer from 18% to 36% by 2030.

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.

Less than half of Medicare patients newly diagnosed with blood cancer are receiving treatment for their cancer shortly after diagnosis, which may be attributed to the high cost burden they face, according to a new report from Milliman commissioned by The Leukemia & Lymphoma Society.

This week, the top managed care news included the average Affordable Care Act premiums falling 4%; the FDA approving a triple combination treatment for cystic fibrosis; House Republicans releasing part 1 of their healthcare plan.

As costs for cancer care continue to rise, Pontchartrain Cancer Center does benefit and cost analyses for all patients before they start therapy and also takes into account any social needs they might have, said Kathy W. Oubre, MS, chief operating officer at Pontchartrain Cancer Center.

Employers did not intentionally set out to address social determinants of health, but the programs they were implementing were doing so, said Michael Thompson, president and chief executive officer of the National Alliance of Healthcare Purchaser Coalitions.

While freestanding emergency departments (EDs) can reduce wait times and reduce the burden on overcrowded EDs, they increase utilization of emergency care and local market spending.

A Colorado-based company, SonderMind, seeks to take on the financial risk associated with reimbursement for mental healthcare so that therapists will be more willing to see patients using their insurance coverage.

The change to the public charge rule has had a negative impact on immigrant patients, who are disenrolling or declining to enroll in Medicaid and are delaying or avoiding care, according to a survey of community health centers.

Mental health care is an area of focus for the National Alliance of Healthcare Purchaser Coalitions, because this care is getting worse despite there being more acceptance regarding the need for improved mental health, said Michael Thompson, president and chief executive officer of the National Alliance of Healthcare Purchaser Coalitions.

More practices than expected seem to be interested in staying in the Oncology Care Model (OCM) and taking on downside risk, said Mike Fazio, senior vice president of client services, Archway Health.

Rare diseases may affect a small number of people, but they have fiscal impacts beyond just healthcare costs. A new study in Orphanet Journal of Rare Diseases used a public economic framework to identify how hereditary transthyretin-mediated amyloidosis has a public economic burden beyond just health costs in the Netherlands.

Although minimal residual disease (MRD) is increasingly being used to predict treatment outcomes and as a surrogate marker of progression-free survival, there remains controversy over whether it is ready to be used in treatment decision making.

High-deductible health plans have been popular, but it’s becoming clear they are not right for all employees, said Michael Thompson, president and chief executive officer of the National Alliance of Healthcare Purchaser Coalitions.

A recent survey of patients with bipolar I disorder showed the extent to which they are so bothered by side effects to antipsychotic (AP) medications that they will stop taking them, or will trade more symptoms for fewer side effects.

The 2019 Kaiser Family Foundation Employer Health Benefits Survey results revealed significant rises in annual premiums, setting the context for the role of health insurance reform during the 2020 election cycle.

While current guidelines recommend that only women with breast cancer who have a family history or who meet clinical criteria undergo genetic testing, a new cost-effectiveness analysis suggests that genetic testing should be expanded to all women with breast cancer.

Low-wage earners in a company face a larger burden in access to care compared with high-wage earners, but not all employers recognize this and design benefits with this in mind, said Thomas Parry, PhD, president and founder of the Integrated Benefits Institute.

The marketplace is working to analyze and clean up real-world evidence so it can be used to inform decisions on treatment and coverage, said Scott Gottlieb, MD, former FDA commissioner (2017-2019).

President Donald Trump has issued an executive order that will protect Medicare and bolster Medicare Advantage (MA) in response to Democrats' Medicare for All proposals.

In the past few years, benefit designs have led to a reduction of both low-value and high-value care, and moving forward, new designs have to be tied more directly to value-based reimbursement, said Michael Thompson, president and chief executive officer of the National Alliance of Healthcare Purchaser Coalitions.

Employers have been talking about low-value care for years, but they’re trying to identify to remove the use of those services, said Michael Thompson, president and chief executive officer of the National Alliance of Healthcare Purchaser Coalitions.

The development and access to orphan indications rely on reimbursement models that require regulatory action toward out-of-pocket costs for patients, said Scott Gottlieb, MD, former FDA commissioner (2017-2019).

In the next 5 to 10 years, providers and health systems need to be thinking about how all the pieces of a new system that delivers holistic, value-based care fit together, said Will Shrank, MD, chief medical officer, Humana, during the opening plenary at the National Association of ACOs fall meeting.