Payer

MMIT Reality Check on Chemotherapy-Induced Nausea and Vomiting (June 2021)

June 11, 2021

According to our recent payer coverage analysis for chemotherapy-induced nausea and vomiting (CINV) treatments, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

According to our recent payer coverage analysis for chemotherapy-induced nausea and vomiting (CINV) treatments, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

To help make sense of this new research, MMIT’s team of experts analyzes the data and summarizes the key findings for you. The following are brief highlights. To read the full piece, including payer coverage, drug competition and prescriber trends, click here.

Payer Coverage: A review of market access for CINV treatments shows that under the pharmacy benefit, about 25% of the lives under commercial formularies are covered with utilization management restrictions.

Trends: New entrants to this market have benefited from rapid uptake, driven both by clinical advantages and by favorable reimbursement dynamics. Merck & Co., Inc.’s Emend (aprepitant) and Aloxi (palonosetron hydrochloride) have the most favorable coverage compared with other brand name antiemetics.

by Matt Breese

Perspectives on MA Prior Authorization Bill

June 10, 2021

A bipartisan bill, which was recently introduced in the House of Representatives by Rep. Suzan DelBene (D-Wash.) and co-sponsored by Reps. Mike Kelly (R-Pa.), Ami Bera (D-Calif.) and Larry Bucshon (R-Ind.), would push health insurers to make “real-time” prior authorization determinations for Medicare Advantage (MA) beneficiaries, AIS Health reported.

According to DelBene’s press release, the Improving Seniors’ Timely Access to Care Act would “establish an electronic prior authorization process, require HHS to establish a process for ‘real-time decisions’ for items and services that are routinely approved, improve transparency by requiring MA plans to report to CMS on the extent of their use of prior authorization and the rate of approvals or denials, [and] encourage plans to adopt prior authorization programs that adhere to evidence-based medical guidelines in consultation with physicians.”

A bipartisan bill, which was recently introduced in the House of Representatives by Rep. Suzan DelBene (D-Wash.) and co-sponsored by Reps. Mike Kelly (R-Pa.), Ami Bera (D-Calif.) and Larry Bucshon (R-Ind.), would push health insurers to make “real-time” prior authorization determinations for Medicare Advantage (MA) beneficiaries, AIS Health reported.

According to DelBene’s press release, the Improving Seniors’ Timely Access to Care Act would “establish an electronic prior authorization process, require HHS to establish a process for ‘real-time decisions’ for items and services that are routinely approved, improve transparency by requiring MA plans to report to CMS on the extent of their use of prior authorization and the rate of approvals or denials, [and] encourage plans to adopt prior authorization programs that adhere to evidence-based medical guidelines in consultation with physicians.”

DelBene’s bill has been endorsed by dozens of provider groups, but payer groups have been silent on the measure.

Michael Lutz, a senior consultant at Avalere Health and a former MA executive at Independence Blue Cross, says some payers and providers are more prepared for prior authorization mandates than others, which has been the case for payer interoperability rules, another tech-oriented regulatory mandate.

“The impacts will be unique to each plan, not necessarily based on the size of the plan,” says Lutz via email. “For example, plans that tightly manage care with expansive Prior Authorization required conditions and services will be more impacted than plans that have few or no prior authorization requirements. Conversely, if done well, the automation of the easier cases may allow plans to free up clinical resources to focus on the complex requests, thus resulting in operational improvements and allowing the clinicians to focus their skills on those cases that most benefit from them.”

“Another impact will be to provider offices,” he adds. “If they don’t have an electronic medical record (EMR) system, are not proficient with its functionality, or don’t have skilled office staff, this could add an additional burden to the provider office.”

Still, Lutz suggests prior authorization changes could be a break-even proposition for health care organizations.

“The big impact will be on implementation costs or the costs of vendor contracts to handle the system build and management. Over time, there may be some balancing with cost savings if the process results in operational efficiencies,” he explains.

MMIT Reality Check on Hereditary Angioedema (June 2021)

June 4, 2021

According to our recent payer coverage analysis for hereditary angioedema (HAE) treatments, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

According to our recent payer coverage analysis for hereditary angioedema (HAE) treatments, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

To help make sense of this new research, MMIT’s team of experts analyzes the data and summarizes the key findings for you. The following are brief highlights. To read the full piece, including payer coverage, drug competition and prescriber trends, click here.

Payer Coverage: A review of market access for HAE treatments shows that under the pharmacy benefit, about 57% of the lives under commercial formularies are covered with utilization management restrictions.

Trends: Health plans don’t differentiate coverage among provider-administered products, and access to HAE products is not limited at the brand level. However, increased competition is expected as more prophylactic therapies enter the market.

by Matt Breese

MMIT Reality Check on Non-Small Cell Lung Cancer BRAF+ (May 2021)

May 28, 2021

According to our recent payer coverage analysis for non-small cell lung cancer BRAF+ treatments, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

According to our recent payer coverage analysis for non-small cell lung cancer BRAF+ treatments, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

To help make sense of this new research, MMIT’s team of experts analyzes the data and summarizes the key findings for you. The following are brief highlights. To read the full piece, including payer coverage, drug competition and prescriber trends, click here.

Payer Coverage: A review of market access for non-small cell lung cancer BRAF+ treatments shows that under the pharmacy benefit, about 71% of the lives under commercial formularies are covered with utilization management restrictions.

Trends: Coverage is under the pharmacy benefit. Prior authorization is required for both Mekinist and Tafinlar to ensure appropriate use. Payer policies for lung cancer typically follow National Comprehensive Cancer Network (NCCN) guidelines.

by Matt Breese

Radar on Market Access: Bipartisan Bill Aims to Reform MA Prior Authorization

May 27, 2021

A bipartisan bill, which was recently introduced in the House of Representatives by Rep. Suzan DelBene (D-Wash.) and co-sponsored by Reps. Mike Kelly (R-Pa.), Ami Bera (D-Calif.) and Larry Bucshon (R-Ind.), would push health insurers to make “real-time” prior authorization determinations for Medicare Advantage (MA) beneficiaries, AIS Health reported.

According to DelBene’s press release, the Improving Seniors’ Timely Access to Care Act would “establish an electronic prior authorization process, require HHS to establish a process for ‘real-time decisions’ for items and services that are routinely approved, improve transparency by requiring MA plans to report to CMS on the extent of their use of prior authorization and the rate of approvals or denials, [and] encourage plans to adopt prior authorization programs that adhere to evidence-based medical guidelines in consultation with physicians.”

A bipartisan bill, which was recently introduced in the House of Representatives by Rep. Suzan DelBene (D-Wash.) and co-sponsored by Reps. Mike Kelly (R-Pa.), Ami Bera (D-Calif.) and Larry Bucshon (R-Ind.), would push health insurers to make “real-time” prior authorization determinations for Medicare Advantage (MA) beneficiaries, AIS Health reported.

According to DelBene’s press release, the Improving Seniors’ Timely Access to Care Act would “establish an electronic prior authorization process, require HHS to establish a process for ‘real-time decisions’ for items and services that are routinely approved, improve transparency by requiring MA plans to report to CMS on the extent of their use of prior authorization and the rate of approvals or denials, [and] encourage plans to adopt prior authorization programs that adhere to evidence-based medical guidelines in consultation with physicians.”

DelBene’s bill has been endorsed by dozens of provider groups, but payer groups have been silent on the measure.

Michael Lutz, a senior consultant at Avalere Health and a former MA executive at Independence Blue Cross, says some payers and providers are more prepared for prior authorization mandates than others, which has been the case for payer interoperability rules, another tech-oriented regulatory mandate.

“The impacts will be unique to each plan, not necessarily based on the size of the plan,” says Lutz via email. “For example, plans that tightly manage care with expansive Prior Authorization required conditions and services will be more impacted than plans that have few or no prior authorization requirements. Conversely, if done well, the automation of the easier cases may allow plans to free up clinical resources to focus on the complex requests, thus resulting in operational improvements and allowing the clinicians to focus their skills on those cases that most benefit from them.”

“Another impact will be to provider offices,” he adds. “If they don’t have an electronic medical record (EMR) system, are not proficient with its functionality, or don’t have skilled office staff, this could add an additional burden to the provider office.”

Still, Lutz suggests prior authorization changes could be a break-even proposition for health care organizations.

“The big impact will be on implementation costs or the costs of vendor contracts to handle the system build and management. Over time, there may be some balancing with cost savings if the process results in operational efficiencies,” he explains.

by Peter Johnson

 

Radar on Market Access: Faxes Led to Improved Statin Use, Prime Study Shows

May 25, 2021

A prescriber fax program alerting physicians when their diabetic patients have not had a statin claim demonstrated a statistically significant boost in statin use and could be a valuable addition to Medicare Advantage Prescription Drug (MA-PD) plans’ efforts to improve both medication adherence and star ratings, according to a new study from Prime Therapeutics LLC, AIS Health reported.

Cholesterol-lowering statin drugs began to play a bigger role in the CMS star ratings in 2019, when the Pharmacy Quality Alliance-developed Statin Use in Persons with Diabetes (SUPD) measure was added to the Part D calculations and when the NCQA-developed Statin Therapy for Patients with Cardiovascular Disease measure was added to the Part C ratings.

A prescriber fax program alerting physicians when their diabetic patients have not had a statin claim demonstrated a statistically significant boost in statin use and could be a valuable addition to Medicare Advantage Prescription Drug (MA-PD) plans’ efforts to improve both medication adherence and star ratings, according to a new study from Prime Therapeutics LLC, AIS Health reported.

Cholesterol-lowering statin drugs began to play a bigger role in the CMS star ratings in 2019, when the Pharmacy Quality Alliance-developed Statin Use in Persons with Diabetes (SUPD) measure was added to the Part D calculations and when the NCQA-developed Statin Therapy for Patients with Cardiovascular Disease measure was added to the Part C ratings.

With the launch of a prescriber fax program in 2019, Prime Therapeutics began identifying diabetic members who did not have a statin pharmacy benefit claim and sending faxes to the member’s prescriber recommending statin therapy. To assess the effectiveness of such a program, Prime researchers monitored the claims of two member groups comprising individuals who had one paid claim for a statin during 2018 and 2019 and were continuously enrolled with one of Prime’s owner/client Blue Cross Blue Shield Medicare plans.

From 2018 to 2019, there was a statistically significant 3.7 percentage-point increase in diabetic members having at least one paid claim for a statin among those exposed to the fax program and a separate pharmacist outreach program offered by Prime, according to the study, which was presented at the Pharmacy Quality Alliance 2021 Online Annual Meeting.

Put another way, researchers found that “78.5% of eligible diabetes members utilized at least one statin in the pre-period for contracts that participated in both the pharmacist outreach and SUPD fax program and 82.2% of eligible diabetes members utilized at least one statin in the post-period for contracts that participated in both the pharmacist outreach and SUPD fax program,” explains Steven Champaloux, principal data scientist and a study co-author.

The SUPD fax program was also associated with a star measure improvement, says Champaloux. “Due to the narrow cutoffs within the SUPD star ratings, a small boost can easily move members into a higher star rating,” he suggests. “Higher health plan star ratings mean better rates for members. Prime is focused on better outcomes and lower costs, so improving this metric is a great way to achieve both.”

by Lauren Flynn Kelly