This Week in Managed Care: October 18, 2019

A new guide balances curbs on opioid abuse with the needs of patients with chronic pain, HHS looks to boost value-based care with changes to anti-kickback rules, And a report finds flaws with Medicaid work requirements.

Welcome to This Week in Managed Care, I’m Laura Joszt.

New Guideline for Reducing Long-term Opioid Use

HHS has released a guide to educate doctors about the need to taper patients off opioids rather than asking patients to stop taking pain medication all at once. Released last week, the guide says a sudden stop or rapid taper risks acute withdrawal symptoms, increased pain, added stress, and suicidal thoughts. Patients may also seek illegal drugs, such as heroin.

The 2016 release of the CDC’s opioid prescribing guidelines brought reports that long-term chronic pain patients who were using opioids properly were having trouble getting medication. Some doctors reported denials for patients with cancer.

Anna Fuqua, a former nurse and patient advocate, told The American Journal of Managed Care^® (AJMC^®) the guide may not go far enough to protect patients.

She said, “I was really pleased to see the clear warnings against rapid taper and rigid application of the dosage thresholds in the CDC guidelines along with the acknowledgement of the resulting risk for serious harm and even death associated with these practices. That said, I don’t believe the strategy proposed here will be efficacious in achieving their stated goal—protecting patients.”

Reforming the Stark Law, Antikickback Rules

After years of discussion, HHS has proposed reforms to antikickback rules contained in the Stark Law, which was written to prevent financial incentives from guiding physician decisions.

The law, written 30 years ago, prevented physicians from referring patients to facilities where they have a financial stake. While it made sense at the time, it limited practices and health systems in a value-based care environment.

HHS said in a statement, “The Stark Law will continue to provide meaningful protection against overutilization and other harms, while giving physicians and other healthcare providers added flexibility to improve the quality of care for their patients.… The proposals would ease the compliance burden for healthcare providers across the industry, while maintaining strong safeguards to protect patients and programs from fraud and abuse.”

Proposed changes to the Stark Law are part of a broader regulatory proposal, called Regulatory Sprint to Coordinated Care.

CMS Administrator Seema Verma said too much regulation adds hundreds of billions of dollars in administrative costs to the US healthcare system each year.

Report Faults CMS for Approved Medicaid Work Requirements

A report from the Government Accountability Office has faulted the Trump administration for approving Medicaid work requirements without factoring in the cost of implementing them. The costs, which range from $10 million to $250 million depending on the state, were inconsistent with federal control standards, the report found.

Since 2018, CMS has approved 9 states’ demonstrations that require beneficiaries to work or participate in other activities, such as training, to maintain Medicaid eligibility. Work rules in Arkansas, Kentucky, and New Hampshire have been set aside due to court challenges.

Ongoing Vaping-Related Deaths

The number of vaping related deaths rose to 29 and injuries total 1299, the CDC reported last week, as the toll keeps rising while public health officials keep searching for the underlying cause. Said CDC’s Anne Schuchat, MD, “I can’t stress enough the seriousness of these lung injuries. We are not seeing a meaningful drop-off in new cases.”

Hardware marketed explicitly for vaping THC oils helped popularize consumption through vaping. Use of concentrates is now the second most popular way to consume THC, behind burning the flower. This vaping has dangerous consequences and should be prohibited https://t.co/6o3VQHpjgk

— Scott Gottlieb, MD (@ScottGottliebMD) October 14, 2019

Meanwhile, former FDA Commissioner Scott Gottlieb, MD, called for a tetrahydrocannabinol (THC) vape ban, due to the connection between these products and the unexplained illnesses. Gottlieb said on Twitter:

Gottlieb, who as commissioner saw the rise of vaping products and then tried to crack down on them, has also called for regulation of marijuana, saying the federal ban is no longer “politically practical.”

You can hear Gottlieb in person at the upcoming AJMC^® event, Patient-Centered Oncology Care^®, which will take place November 8 at the Sofitel Hotel on Rittenhouse Square in Philadelphia.

Obesity and Cancer Rates

Finally, the new issue of Evidence-Based Oncology™ (EBO) examines the connection between rising obesity rates and certain types of cancer, including liver cancer. Cover stories examine how cancers related to obesity are being diagnosed in younger patients as obesity rates climb, and what this means for the health system.

Articles include:

• A discussion of nonalcoholic steatohepatitis and liver cancer by Donna Cryer, president and chief executive officer of the Global Liver Institute
• An overview of the rise of obesity and cancer as a public health crisis, by EBO Editor-in-Chief Joseph Alvarnas, MD, and Alexander Alvarnas,
• An interview with Debra Patt, MD, MPH, MBA, of Texas Oncology on how obesity can alter the treatment path and effectiveness of certain cancer regimens. For the full issue, visit ajmc.com.

For all of us at AJMC^®, I’m Laura Joszt. Thanks for joining us.