CMS Issues Final Rule on Medicare Advantage Prior Authorization Requirements
The US Centers for Medicare and Medicaid Services (CMS) has issued its final rule on prior authorization requirements for Medicare Advantage (MA) plans. The rule changes ensure that prior authorization approvals last as long as medically necessary, that plans must only use prior authorization policies to check diagnoses, and that plans must give beneficiaries a 90-day transition period when changing plans.
States Increasingly Coordinating Care for Dual Eligibles with Managed Care, FAIs, and PACE
Dual eligible special needs plans often run up against significant difficulties coordinating care for beneficiaries. A recent analysis by the Kaiser Family Foundation (KFF) examined how states accomplish this complex task, finding that many use managed care, a Financial Alignment Initiative (FAI), or rely upon the Program of All-Inclusive Care for the Elderly (PACE).
Immunotherapy Utilization Lower at Small and Rural Clinics
A recently published article in JAMA Oncology finds that cancer clinics that are smaller or in rural areas are less likely to use immunotherapy for their patients compared to larger clinics and those in urban and suburban areas. The study, based on Medicare claims data taken from 1700 cancer clinics, also showed that the majority of practices implemented new immunotherapies within 2 years of their approval by the US Food and Drug Administration (FDA).
CMS Announces New Rules to Improve Medicaid and CHIP Programs
In two back-to-back announcements, the US Centers for Medicare and Medicaid Services (CMS) has revealed policies targeting healthcare access and quality for patients on Medicaid and the Children's Health Insurance Program (CHIP) The rules changes would standardize fee-for-service (FFS) reimbursement rates and improve access for both programs.
Study Finds Safety-Net Hospitals with High Uncompensated Care Rates in Disadvantaged Areas Have Lower Margins
A recently published study in Health Affairs finds that safety-net hospitals’ margins are lower in disadvantaged areas or when they have high rates of uncompensated care. The Disproportionate Share Hospital (DSH) program was designed to compensate hospitals who treat underserved communities, but state-level policies can cause disparities in payments to different health centers.
Using Real-World Evidence to Advance Geometric Atrophy Care
Despite advances in treating geometric atrophy (GA), a progressive eye disorder, patient responses to treatment are variable. In a new interview with AJMC, Ashard Khanani, MD, talks about how real-world evidence (RWE) can help advance GA care by revealing the real-world impact of treatments on patient health outcomes.
Study Finds Medicaid Supplement Payments Need Restructuring
Research released by the Robert Woods Johnson Foundation finds that Medicaid supplement payments are inefficiently distributed, requiring a significant overhaul to fix. For example, disproportionate share hospital payments are based on figures from 1992 and leave some states receiving less than $100 for uninsured patients, much less than the $1,500 that others receive per uninsured patient.
Medicaid Redetermination Process to Take Coverage from Millions of Children
With the COVID-19 public health emergency on its way out, states are set to start up the redetermination for Medicaid beneficiaries. Among the millions who will lose healthcare coverage in this process are children, who make up the majority of Medicaid recipients. The number of children to be dropped is still uncertain, but it is estimated to be around 1/3 of kids on the program.
Value-Based Care Front and Center at NAMCP Spring Forum
Value-based care will be a major theme of discussion at this week’s National Association of Managed Care Physicians (NAMCP) Spring Managed Care Forum. In addition, speakers will cover managed care decision-making in a variety of disease contexts, covering how to improve patient outcomes and reduce costs. The final focus is oncology.
FDA Approves Medtronic’s Automatic Insulin Pump
Meditronic has scored a win with the long-anticipated approval of its MiniMed 780G insulin pump by the US Food and Drug Administration (FDA). The pump, which works in concert with the company’s Guardian 4 continuous glucose monitor to allow for automated insulin management, even bolus injections which weren’t automated by the previous version.
Integrating Behavioral Health and Primary Care Through Value-Based Payment Models
To improve patient mental health outcomes and reduce healthcare costs, behavioral health needs to move to a value-based payment model and be better integrated into primary care. However, significant hurdles stand in the way. Payers could play a pivotal role in addressing the problem, but this will require careful cooperation with providers.
HIMMS Insights: Health Tech Solutions Must Account for Health Equity
Several talks and presentations at this year’s Health Information and Management Systems Society (HIMMS) meeting emphasized the need to factor health equity into health technology solutions. Speakers covered topics ranging from the need to target nutrition as preventative care to the disruptive impact of artificial intelligence (AI) models.
How Will AI Continue to Impact Digital Health
Artificial Intelligence (AI) is increasingly being implemented as part of the development or operation of digital health solutions. The technology is not without significant ethics issues, however, namely the introduction of human bias and how the technology is used. In a new PM Live article, Matt Lewis of Inizio Medical discusses the future of AI in digital health.
Turning Interoperability Talk into Action
Despite significant public and private efforts, healthcare IT systems are usually not interoperable, impacting patient care, reimbursement, and research alike. As a result, real action is needed to turn ongoing discussions about interoperability into action. One way forward may be focusing on application with the people who use the systems most.
NICE Approves Combo Therapy for Leukemia by J&J and Abbvie
The UK’s National Institute of Health and Care Excellence (NICE) has issued its approval of J&J and Abbvie’s combination therapy of Imbruvica and Venclyxto for use as a first-line treatment of chronic lymphocytic leukemia (CLL). The combo will be released as a pill taken once per day, the first of its kind for a CLL chemotherapy drug.
Program Targeting Food Insecurity Cut Healthcare Costs for People with Type 2 Diabetes
Food insecurity leads to a poor diet that can exacerbate symptoms of type 2 diabetes, significantly increasing healthcare costs for patients and payers. A recent program by Pack Health targeted food insecurity by delivering meals and providing education to food-insecure people with diabetes type 2. Results showed that the program cut healthcare costs by $139 per month and improved health outcomes.
CMS Health Equity Metric May Exacerbate Disparities in Some Areas
The Area Deprivation Index (ADI) is a metric that assesses the socioeconomic conditions of an area to determine if it is deemed disadvantaged. The US Centers for Medicare and Medicaid Services (CMS) uses the ADI in new payment models that reward providers for serving disadvantaged areas to promote health equity efforts. However, many areas have wealthy people living in close proximity to poorer communities, skewing results and precluding many disadvantaged communities from these initiatives.
US Supreme Court Pauses Texas Judge’s Ruling to Revoke FDA Approval of Mifepristone
Following calls to act on a ruling from a Texas federal judge that would overturn the US Food and Drug Administration’s (FDA’s) approval of the abortion drug mifepristone, the Supreme Court has stepped in and placed a 5-day hold on the lower court’s decision. The temporary stay will last until Wednesday, April 19th.
Real-World Evidence Study Finds Cefiderocol Effective Against Antibiotic-Resistant Bacterial Infections
Shionogi & Co., Ltd. will present real-world evidence (RWE) showing that its antibiotic Fetcroja (cediferocol) is effective at treating infections caused by antimicrobial-resistant Gram-negative bacteria. The results, which will be shared at this week at the European Congress of Clinical Microbiology & Infectious Diseases.
Finch Ratings: Medicaid Disenrollment Set to Financially Impact Not-For-Profit Hospitals
A new analysis from Finch Ratings finds that non-profit hospitals’ bottom lines will be hurt by upcoming Medicaid disenrollment triggered by the imminent end of the COVID-19 public health emergency. Many patients going to not-for-profit hospitals were covered by Medicaid expansions. Since a large number of these patients will be disenrolled, Finch predicts that they will have to receive charity care that hospitals will not be paid for, hurting their revenue.
Real-World Data Shows Black People Face Higher Rates of Insomnia and Receive Poor Care
A growing body of research indicates that Black people in the US have significantly higher levels of sleep disorders like insomnia and sleep apnea than their white counterparts. Despite this, Black patients typically receive substandard care for sleep problems. A real-world data (RWD) study earlier this year found that only 6.2% of Black patients diagnosed with insomnia received medication for it, less than half the rate of white patients.
CMS Publishes Proposal to Improve the Prior Authorization Process
The US Center for Medicare and Medicaid Services’ (CMS’s) Interoperability and Patient Access Final Rule ensures patient acccess to clinical data, adjucated claims, and other health information. The newly published Advancing Interoperabilty and Improving Prior Authorization Processes Proposed Rule would, if implemented, extend the prior rule with 5 key proposals targetting health data access and prior authorization.
FDA Releases Guidance on Patient-Centered Drug Development
A final draft guidance regarding patient-focused drug development (PFDD) has been issued by the US Food and Drug Administration (FDA). The guidance covers data collection methods about patient care experiences and how they can be used in regulatory decision-making processes, specifically clinical outcomes assessments (COA).
NIH Announces Winners for RADx Tech Maternal Health Challenge
The US National Institutes of Health (NIH) announced the next round of winners selected to move forward in the Rapid Acceleration of Diagnostics Technology (RADx Tech) for Maternal Health Challenge, a contest to develop and assess digital health solutions to reduce post-partum maternal mortality. The winners will be awarded $75,000 for their efforts and entered into the next round of competition.
Unlocking the Potential of Price Transparency Data to Advance Value-Based Care
Despite new rules in the US requiring providers to collect and report pricing transparency data, just over three quarters of hospitals are lagging behind. If this data can be accurately collected and analyzed, it could help establish fair value-based pricing models that could benefit both patients and providers. In addition, the law targets payer-related data.
