Site of Care Management

Study: 25% of Medicaid Docs Provide At Least 75% of Care

About a quarter of the practitioners in Medicaid managed care organization networks provide more than three-quarters of the services used by members, according to an article published by researchers affiliated with Yale and Cornell Universities in the journal Health Affairs this month. Experts say that this concentration of care likely limits access to care for members, and health plans need to do more to make sure their networks aren’t made up of so-called “ghost providers.”

The article, which analyzed claims and enrollment data from Kansas, Louisiana, Michigan and Tennessee during 2015-17, found that care delivery is highly concentrated in both primary care and specialists. However, the authors caution that their study of the states “might not generalize nationally” and only studied four specialties.

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Specialty Pharma Payer Deals Point to Outsourcing Trend

As prices for specialty pharmacy products continue to soar, payers are looking for new ways to gain more control over the distribution of expensive, often-provider-administered drugs. Last week, Kaiser Permanente and Highmark Blue Cross Blue Shield both struck deals aimed at managing specialty pharmacy spend — and one expert says that more deals like them are coming, especially from Kaiser’s new business partner, Cigna Corp. subsidiary Evernorth.

Kaiser Permanente (KP), the multistate integrated payer-provider based in California, doesn’t enter agreements with service providers outside its self-contained system very often. That said, Kaiser Permanente spokesperson Stephen Shivinsky tells AIS Health that “Kaiser Permanente and Accredo” — the specialty pharmacy division of Evernorth — “have had an existing relationship, which will expand further under part of this new agreement.”

Specialty Pharma Payer Deals Point to Outsourcing Trend

As prices for specialty pharmacy products continue to soar, payers are looking for new ways to gain more control over the distribution of expensive, often-provider-administered drugs. Last week, Kaiser Permanente and Highmark Blue Cross Blue Shield both struck deals aimed at managing specialty pharmacy spend — and one expert says that more deals like them are coming, especially from Kaiser’s new business partner, Cigna Corp. subsidiary Evernorth.

Kaiser Permanante (KP), the multistate integrated payer-provider based in California, doesn’t enter agreements with service providers outside its self-contained system very often. That said, Kaiser Permanente spokesperson Stephen Shivinsky tells AIS Health that “Kaiser Permanente and Accredo” — the specialty pharmacy division of Evernorth — “have had an existing relationship, which will expand further under part of this new agreement.”

Patients Love Telehealth, but Could Doctors Dislike It?

Virtual care has become a mature industry during the COVID-19 pandemic, with insurers and investors pouring money into telehealth startups. But the telehealth boom has changed how practitioners deliver care in ways that they don’t necessarily like, according to a new survey from McKinsey & Co. Though telehealth is here to stay, much remains unsettled about the way physicians use virtual care tools — and how they are paid to do so.

Nearly every physician now uses telehealth, according to McKinsey, and the change happened fast: 83% of physicians that the consulting firm surveyed in 2021 offered virtual services, versus 13% in 2019. The survey also found that by May 2021, 88% of consumers had used virtual care since the start of the pandemic.

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Optum Aims to Cut Specialty Spend With Management Tool

UnitedHealth Group’s Optum division recently unveiled an analytics-fueled medication management system aimed at tackling rising costs in the specialty drug market. The company says the new product, known as Specialty Fusion, has the capability to generate significant savings while reducing administrative burden for prescribers.

Positioned as a solution for commercial health plans, Specialty Fusion is designed to integrate medical and pharmacy benefit data into a single point-of-service management system. According to Optum, the Specialty Fusion system differs from other solutions on the market because it provides “a full integration” of medical and pharmacy benefits. The system incorporates various cost determinants at the point of care, such as available rebates, lower cost sites of care and manufacturer assistance programs, in addition to a carousel of more affordable drug therapies.

Many Melanoma Therapies Exist, but Treatment Remains Challenging

Since 2011, the FDA has approved multiple therapies for advanced or late-stage melanoma. Recently, the agency granted an additional approval to one of those drugs for the earlier stage melanoma setting, filling an unmet need, industry experts note. However, the condition is complex to treat and may be challenging for health plans to manage.

On Dec. 3, the FDA approved Merck & Co., Inc.’s programmed death receptor-1 (PD-1) inhibitor Keytruda (pembrolizumab) for the adjuvant treatment of people at least 12 years old with stage IIB or IIC melanoma following complete resection. The agency also expanded the indication for the agent’s use as an adjuvant treatment of stage III melanoma following complete resection to include pediatric patients at least 12 years old.

What Will Be Impact of Allowing Abortion Pill to be Mail-Ordered?

Earlier this month, as the debate over legal abortion in the U.S. intensified, the FDA removed a requirement that the pregnancy-ending drug mifepristone be dispensed only in clinics, medical offices and hospitals. That move will effectively open the door for “certified prescribers or pharmacies” in states that haven’t already banned the practice to dispense mifepristone by mail.

Experts tell AIS Health, however, that there are more questions than answers about how those loosened regulations will ultimately affect patient access to the controversial drug, as well as how industry players such as health plans and PBMs will be affected.

Non-Emergent 911 Calls Offer Intervention Opportunity

Not every person who calls 911 needs to be transported to a hospital for emergency treatment. But people who make those phone calls do need some kind of health care; they just don’t know how to access the services they need.

With that in mind, the health insurer CareOregon recently made a $2.5 million investment in a new Portland Fire & Rescue (PF&R) initiative to connect community members with the care they need. The Community Health Assess & Treat (CHAT) program will take a proactive approach to assessing and meeting the needs of members of Oregon Health Plan, the state’s Medicaid program.

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