August 13, 2018

CMS Moves To Overhaul Medicare ACOs

CMS last week issued a proposed rule, which would make major changes to the Medicare Shared Savings Program (MSSP). In this rule, CMS proposes to redesign the MSSP, eliminating Track 1 and 2, establishing a new BASIC track and reframing Track 3 as an ENHANCED track.  In an August 9th post to Health Affairs (click here), Administrator Seema Verma says CMS will streamline the existing MSSP program, incorporate higher levels of risk for the ACOs, empower and incentivize patient participation in ACOs, and save Medicare as much as $2.2 billion over ten years.

— Existing ACOs with agreements ending December 31, 2018 can extend their agreement six months until June 30, 2019.

— CMS proposes allowing ACOs to begin under a one-sided model and incrementally phase-in higher levels of risk. The highest level of risk would be equivalent to Track 1+ and qualify as an Advanced Alternative Payment Model under the Quality Payment Program.

— Click here for the CMS fact sheet. Click here to read the 607-page proposed rule.  Comments are due to CMS October 18.

  • The National Association of ACOs blasted the CMS proposal. Click here.
  • Former Obama CMS Administrator Don Berwick said “a chilling of interest” in teams participating “may be the wrong direction.” Click here for that story.
  • A new report out last week by the Patient-Centered Primary Care Collaborative shows that there are benefits for ACOs that leverage advanced primary care models because those models are generally seeing more cost savings and higher quality outcomes. Click here for the report.


CMS Proposes Drug Step-Therapy To Curtail Rx Costs
CMS last week released the details of a new policy for Medicare Advantage that will allow plans the option to apply step therapy for physician-administered and other Part B drugs. However, CMS will require plans to also share half of savings from step therapy with beneficiaries. CMS is using Medicare Advantage, which covers 33 percent of beneficiaries, to accomplish its goals of bringing plan negotiations to Part B. Step therapy generally requires a patient to start with the most lowest cost drug option and “stepping-up” to higher cost drugs if needed for medical reasons. Additionally, insurance companies give prior approval before more costly medications are administered to patients. CMS estimates the new policy will reduce spending on drugs by 15 percent to 20 percent per year. Click here for more on the policy from CMS.

  • There could be a legal challenge (both pharmaceutical manufacturers and physician groups are against the policy) based on a memo from the Obama Administration in 2012 that stated that step therapy is legally forbidden in Medicare Advantage, click here.
  • Many physicians view step therapy as just another form of prior authorization.  Click here.

Studies: Provider, Payer Consolidation Has Big Impact on Health Care Costs
Health care provider concentration, more than insurer consolidation, is likely leading to higher costs, according to a new study. Researchers looked at how market concentration varied among providers and payers across the U.S. for each metropolitan statistical area in 2016. The authors found that there was vast variation in market concentration and that high payer concentration can give health insurers more bargaining power to reduce prices. However, most markets had a much higher concentration of providers vs. payers leading to cases of higher cost. To read the blog post about the study, click here.  Another study in Health Affairs shows that premiums were 50-percent higher in 2018 in areas with a single insurer as compared with those with two or more, click here.
GM Strikes Innovative Health Care Deal with Henry Ford Health System 
Michigan-based General Motors last week announced that it had a agreed to a five-year contract with Detroit’s Henry Ford Health System to provide direct care for its 24,000 employees and their dependents. This follows other U.S. companies, such as Intel and Boeing, who have begun testing direct health care delivery deals for a way to save costs. Under the contract, Henry Ford will be held accountable for 19 separate metrics and hit an annual financial budget requirement. The plan, GM ConnectedCare, is expected to save anywhere from $300 to $900 per employee annually. Click here for the HFHS press release.  For more on the program, click here.  Click here for the WSJ report.

  • To say the medical marketplace is changing fast would be a clear under-statement. Click here to read more on the four major trends shaping the future of health care.

Health Equity Coalition to Host Third Summit on Social Determinants

The Root Cause Coalition, a non-profit, member-driven organization established to achieve health equity through cross-sector collaboration, will host its third annual National Summit on the Social Determinants of Health on October 7-9 at the Sheraton New Orleans Hotel. The Coalition is comprised of 56 leading health systems, hospital associations, foundations, businesses, national and community nonprofits, health insurers, academic institutions and policy centers. The Sheraton will be host to hundreds of leaders with experience implementing programs that address the social factors that weigh so heavily on health outcomes. The summit is an unparalleled opportunity to hear from experts in health and human services, health policy, education, research, and the nonprofit sector as they discuss and showcase proven social determinant interventions. Click here to register.

Medical Transportation Is a Booming National Need

As America’s baby boomers are hitting 65 at a rate of 10,000 a day, and healthier lifestyles are keeping them in their homes longer, demand is escalating for a little talked-about — yet critical — health care-related job: Transporting people to and from non-emergency medical appointments.  It’s no longer enough to call a taxi or regular car service and hope that frail seniors can get in and out — or through the entrance of a doctor’s office on their own as the driver speeds off. For people requiring oxygen tanks and wheelchairs, it’s an even bigger challenge, and long waiting periods are often required to arrange for specially equipped vehicles. Those needing transportation and specialized drivers covered by their insurance often have to wade through another labyrinth of red tape. Click here for this special report from the NYTimes.

GOP Heavyweights Urge OMB To Tread Softly on Eliminating Drug Rebate Program

In a letter sent last week, two Republican committee chairmen asked OMB Director Mick Mulvaney to consider the full economic effects of HHS’ proposed rebate rule, marking the first public congressional concern over eliminating the system allowing rebates between drugmakers and insurers and pharmacy benefit managers. Senate Finance Chairman Orrin Hatch (R-UT) and House Energy and Commerce Chairman Greg Walden (R-OR) urged Mulvaney to ensure that the rule — which could peel back safe harbor protection for rebates from an Anti-Kickback law — include a robust regulatory impact analysis before it’s cleared for publication. Click here for their letter. Click here for more on the drug rebate proposed rule.
Health Issues Reported for 1 in 7 Babies Born to Zika-Infected Mothers
The Centers for Disease Control and Prevention reports that one in seven babies born to Zika-infected mothers have health problems possibly linked to the mosquito-borne virus. About 14 percent of the 1,450 children born in the US Zika territories had either a birth defect associated with Zika, a neurodevelopmental abnormality possibly caused by the virus or both. Of those infected, 6 percent had birth defects including small head size, brain damage or eye damage and 9 percent had medical issues including seizures, developmental delays and problems swallowing or moving. Click here for the report.

IBM’s Watson Not Measuring Up on Oncology: Wall Street Journal

Six years and billions of dollars later, the diagnosis for Watson is gloomy. More than a dozen IBM partners and clients have halted or shrunk Watson’s oncology-related projects. Watson cancer applications have had limited impact on patients, according to dozens of interviews with medical centers, companies and doctors who have used it, as well as documents reviewed by the WSJ. In many cases, the tools didn’t add much value. In some cases, Watson wasn’t accurate. Watson can be tripped up by a lack of data in rare or recurring cancers, and treatments are evolving faster than Watson’s human trainers can update the system. Click here for the story.


Study Points to Pets as a Way to Help Unresponsive Depression
A study has shown that pets increase the effectiveness of medication on unresponsive depression. Depression can be treated with medication but sometimes medication does not work and thus it is labeled as “unresponsive”. The study looked at 80 patients who have unresponsive depression and encouraged them to adopt a pet. When having a pet a third of the participants were found to no longer meet the conditions of depression after only two months. The full study is available here.
Dizziness on Standing Could be Risk Factor for Dementia and Stroke
Feeling dizzy or lightheaded on standing may increase your risk for stroke and dementia later in life. Orthostatic hypotension is a condition caused by a sharp drop in blood pressure when rising from a lying down position, often marked by a feeling of sudden dizziness. A new study published in the journal Neurology analyzed data from 11,709 participants without a history of coronary heart disease or stroke over 16 years and found that people with orthostatic hypotension had a 54 percent higher risk of dementia and more than double the risk of stroke. Researchers suggest checking in with your doctor if it happens regularly. Link to study (subscription needed) available here.

Pregnant Women Addicted to Opioids Quadrupled over 15 Years

As the opioid epidemic continues to wreak havoc across the country, a new report from the Centers for Disease Control and Prevention (CDC) sheds light on the devastating consequences opioid addiction can have on pregnant women. The CDC analysis found that the number of women with opioid use disorder (OUD) at labor and delivery more than quadrupled from 1999 to 2014. Click here for the CDC report.
Opioid Prescriptions Decrease with Fatality Reminders
A new study published in Science looks at how to curtail physician’s willingness to prescribe opioids to their patients. In the study, letters were sent to San Diego area physicians informing them of overdose deaths of patients whom they had prescribed medication to. Among recipients, prescriptions following the letter decreased by 6.2-13.2%. Researchers found that of 170 patients in a study looking at those who overdosed on opioids, only five and a half prescribers on average were responsible for providing them the medication.  To read the entire study, click here.

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