Most Managed Care Plans Are Missing Medicaid Patient Contact Information
As the Medicare redeterminations and the end of the COVID PHE approach, many Medicaid managed care plans are ill-equipped to inform all their members about their status. A recent survey released by the Kaiser Family Foundation found that nearly a third of Medicaid plans have up-to-date contact information for 75% or more of their members.
Oppenheimer Analysts: Keep an Eye on Managed Care
A note to clients from Oppenheimer recommends that investors carefully watch managed care industry. Analysts say that a group of major managed care firms like Centene, Cigna, and UnitedHealth, have underperformed so far this year, in part because uncertainty surrounding the impending end of the COVID-19 public health emergency.
5 Recommendations to Revamp Dementia Care Payment Models
Care for people living with Alzheimer’s and related dementias (ADRD) is emotionally taxing for caregivers and costly for Medicaid, which spent $146 billion on ADRD care in 2022 alone. In a newly published article in Health Affairs, authors give 5 recommendations to help revamp ADRD care payment models to reduce the burden on Medicaid and caregivers.
Seven Payer Exec’s Takes on Medicaid Redeterminations
State will shortly begin the Medicaid redetermination process as the pandemic-era continuous coverage requirements expire with the end of the COVID-19 public health emergency. This leaves many payers preparing to lose members. Learn what 7 different payer execs expect with the redetermination process in a new Becker’s Payer Issues article.
US Nursing Homes are Facing a Profitability Crisis
The American Healthcare Association (AHCA) has announced that over half of nursing homes in the US are unprofitable, leaving the future of long-term care in question. The report found that key contributors include increasing prices for drugs and medical supplies, Medicaid payments that are lower than the cost of care, and a decreased patient population.
Drug Price Inflation on the Rise
A new market projection by Vizient projects that inflation in drug prices is set to grow throughout the year, despite many drugs going generic or having biosimilars enter the market. The firm predicts that the drug price inflation rate will reach 3.78%, a jump from 2021’s increase of 3.2%.
Eisai Preps for Alzheimer’s Drug Launch
With the first patients receiving Leqembi last week, the new Alzheimer’s drug’s manufacturer Eisei is plotting out the drug’s rollout with last year’s Aduhelm controversy in mind. As such, the company, which received approval for the drug this January, is taking things slow and working carefully with payers to secure reimbursement ahead of a potential full approval in the near future.
CMS Leaders Propose Universal Foundation for Quality Measures
The US Centers for Medicare and Medicaid Services (CMS) has several varying sets of quality measures with some degree of [...]
Millions of Medicaid Beneficiaries Likely to Lose Coverage When Continuous Enrollment Ends
Medicaid enrollees must reapply every year in a complicated process fraught with hidden pitfalls that could sink one’s coverage. This [...]
Exploring Value-Based Drug Pricing Models
Value-based care, a kind of payment model that determines reimbursement based on patient care outcomes, has become more prevalent in recent years. Such a change has not been seen in prescription drug prices, despite the advent of multi-million dollar therapies that can radically change a patient's course of care. In a new Med City News article, learn how value-based payment models for prescription medications may be a path towards more affordable drug prices.
Uncertainty Surrounds Payment Models for World’s Priciest Therapeutic
With the US Food and Drug Administration’s (FDA’s) approval last year of Hemgenix, a hemophilia B gene therapy by CSL Behring and most expensive drug in history, insurers are looking to the Centers for Medicare and Medicaid Services (CMS) for new payment models. The agency has long been used as a model for pricing decision-making, especially for novel, expensive medications.
In-Person Care and Telehealth Private Insurer Payments Similar in 2020
A new analysis by the Kaiser Health Foundation finds that reimbursements from private insurance plans were similar for in-person and telehealth appointments during 2020. The researchers analyzed data from over 90 million claims. The average cost for telehealth visits covering serious evaluation and management cases for established patients was $143, whereas in-person services were, on average, only a few dollars cheaper at $137.
JAMA Network Study Shows Quality of Care Doesn’t Mitigate High Out-Of-Pocket Healthcare Costs
A newly published study in JAMA Network has found that no matter whether the quality of care for emergency general surgery (EGS) is good or subpar, the out of pocket (OOP) costs are uniformly high. The researchers looked at 23,450 patients admitted for several common causes of EGS at over 600 facilities from 2016 to 2019.
NAHC President Tells Home Care Providers to Keep an Eye on Medicare Advantage
At a webinar this week, the president of the National Association for Home Care & Hospice (NAHC) Bill Dombi said that Medicare Advantage plans are on the rise and that home care providers should pay attention. Dombi noted that there is a huge marketing force driving the boom, with big celebrity names behind it.
Inflation Might Have a Good Side? – Managed Healthcare Executive State of the Industry Survey
In its latest annual State of the Industry survey, Managed Healthcare Executive found that many respondents saw there could be a good side to inflation for the healthcare sector, despite its many negative effects. Many predict layoffs, decreases in care, increased spending, and costs being shifted to patients and their employers.
CMS Examines Coverage Options for HIV PrEP Preventative Care
A new analysis has been launched by the US Centers for Medicare and Medicaid Services (CMS) to evaluate the nationwide coverage of HIV preexposure prophylaxis (PrEP), a group of antiretroviral drugs that prevent HIV infections and transmission when taken appropriately. The drugs, which hover at around $2300 a year, fall under Medicare coverage for some states but not all.
Patient Advocacy Groups Butt Heads with CMS Over New Alzheimer’s Drug Coverage
With the accelerated approval of lecanemab, Eisei and Biogen’s new Alzheimer’s drug, patient advocacy groups are gearing up for another fight with the US Centers for Medicare and Medicaid Services (CMS) over the agency’s previous decision not to cover drugs in its class unless patients are enrolled in clinical trials. If nothing changes, many patients would have to pay the full list price of $26,500 for one year of treatment.
Zerenia Clinic Receives First NHS Reimbursement for Cannabis-Based Treatment
Zerenia Clinics has achieved a new milestone for by receiving full reimbursement from the UK’s NHS for costs related to cannabis-based treatments. The company, owned by Khiron, noted that the reimbursement is their first of its kind for outside clinics that specialize in cannabis-based products for medicinal use in humans (CBMPs).
HHS to Pick Drugs Subject to Medicare Price Negotiations by September
In an announcement this week, the US Department of Health and Human Services has revealed its schedule for the leadup to Medicare drug price negotiations, as granted by the Inflation Reduction Act. While negotiations don’t commence until 2026, the list of 10 drugs to be negotiated will be released in early September, with a public comment phase this spring.
Value-Based Contracts on the Rise
With the increasing adoption of high-price biologic therapies that offer potential long-term relief for small patient populations, other payment models like value-based contracts are being hotly debated by pharma, providers, and payers. These models account for the long-term benefits of the treatments and whether a given patient actually sees such effects.
North Carolina May See Last Medicaid Expansion in Some Time
The US state of North Carolina will soon vote on whether to expand Medicaid coverage within the state, thereby potentially leaving the ranks of states that have not expanded Medicaid to 10. Republican opposition to the expansion has shifted in the state legislature, with some top former opponents flipping sides.
APAC Therapeutic Access and Financing Trends to Watch in 2023
The market access and reimbursement landscape in APAC is set to shift in 2023, according to a new interview with Jeff Weisel, APAC managing director for PRMA Consulting. Weisel notes that global economic forces will play a significant role in payer decision-making in APAC, with inflation and the strengthening dollar being counterbalanced by the availability of biosimilars.
Paxlovid Not on China’s Reimbursement List
As the nation phases out its zero-COVID strategy following major protests, China’s National Healthcare Security Administration has left Pfizer’s Paxlovid off its reimbursement list. This comes as cases spike in the nation, with many patients purchasing the drug off the internet through India. However, other COVID drugs did make the cut.
CMS Lets States Cover Nonmedical Services for Medicaid Beneficiaries
Social determinants of health (SDoH) like housing instability and food insecurity dramatically impact patient health outcomes. To address these factors, the US Centers for Medicare and Medicaid Services (CMS) has issued a new guidance that allows states to offer benefits for nonmedical services, under the classification of “in lieu of services and settings.”
FDA Approves Alzheimer’s Treatment by Biogen and Eisai
The US Food and Drug Administration (FDA) has approved Biogen and Eisai’s new Alzheimer’s drug, lecanemab. The drug is the first of its kind because it slowed cognitive decline in patients, a sticking point with the ill-fated Aduhelm that was pulled from the market last year. However, it is unclear whether payers will cover the therapy, which looks to be expensive.
