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Radar On Market Access: Insurers Welcome Changes to Addiction Treatment Privacy Rules

September 10, 2019

A recent federal proposal — which would loosen privacy rules surrounding substance use disorder (SUD) treatment — is being applauded by health insurer trade groups. But some advocates are worried about potential harms to patients, AIS Health reported.

A recent federal proposal — which would loosen privacy rules surrounding substance use disorder (SUD) treatment — is being applauded by health insurer trade groups. But some advocates are worried about potential harms to patients, AIS Health reported.

At the center of the debate is legislation enacted in the 1970s and the subsequent regulations implementing that law, known as 42 CFR Part 2, which was designed to protect the confidentiality of SUD patient records created by federally funded treatment programs. Under the proposed changes to 42 CFR Part 2, opioid treatment programs would be able to enroll in state prescription drug monitoring programs and submit the dispensing data for controlled substances consistent with applicable state laws. SUD patients also would be able to consent to disclosure of their Part 2 treatment records to an entity, without having to name a specific person.

“At the highest level, ACHP does see the proposed rule as a positive development,” says Connie Hwang, M.D., chief medical officer of the Alliance of Community Health Plans. When an individual is undergoing treatment for SUD, “you want to make sure that all the other groups engaged in the ongoing care are aware and don’t inadvertently interfere with that or put the patient at greater danger,” she adds.

However, not everyone shares that view.

“While the Legal Action Center strongly supports the need for coordinated flow of health information between providers, it must be done so with patient consent in disclosure and re-disclosure,” Paul Samuels, president and director of the advocacy group, said in a news release.

The current privacy rules are “a necessary protection for individuals who would otherwise be susceptible to a multitude of detrimental consequences if their SUD information was disclosed without their permission to potential employers, housing providers, law enforcement and more,” Samuels added.

MMIT Reality Check on Breast Cancer HER2+ (Sep 2019)

September 6, 2019

According to our recent payer coverage analysis for breast cancer (HER2+) treatments, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

According to our recent payer coverage analysis for breast cancer (HER2+) 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 breast cancer (HER2+) treatments shows that under the pharmacy benefit, about 32% of the lives under commercial formularies are covered with utilization management restrictions.

Trends: In July 2019, Amgen Inc. and Allergan plc launched oncology drugs Mvasi
(bevacizumab-awwb), an Avastin (bevacizumab) biosimilar, and Kanjinti (trastuzumab), a Herceptin (trastuzumab) biosimilar.

Perspectives on Trump’s Drug Importation Plan

September 5, 2019

Amid an ongoing outcry against rising drug costs, the Trump administration recently introduced two importation pathways to reduce what U.S. residents pay for drugs, AIS Health reported.

Amid an ongoing outcry against rising drug costs, the Trump administration recently introduced two importation pathways to reduce what U.S. residents pay for drugs, AIS Health reported.

Under the Safe Importation Action Plan, the first pathway would allow states, wholesalers and pharmacists to propose to HHS demonstration projects for importing certain drugs from Canada. Under the second pathway, drug manufacturers could import non-U.S. countries’ versions of their drugs into the United States.

What do health plan executives need to worry about with these two pathways? Not much, at least not in the next couple of years, according to Jigar Thakkar, Pharm.D., a managing director at FTI Consulting.

“There are so many hurdles that this isn’t something that’s going to happen tomorrow or in the next year or two,” Thakkar says. The hurdles include passage of legislation to allow biologics such as insulin to be imported and the ability of drugs imported from other countries to be tracked via FDA-TRACK, the FDA’s agency-wide performance system that monitors drugs during their journey from manufacturer to distributors to pharmacies.

Another significant hurdle is pushback from interest groups in Canada. Bloomberg News reported that the Canadian Medical Association and 14 other groups sent a letter to Canada Health Minister Ginette Petitpas Taylor protesting the Trump administration’s moves.

Deb Devereaux, senior vice president of pharmacy at Gorman Health Group, isn’t optimistic about the success of the first pathway where drugs would be imported to the United States from Canada. “The bottom line is the Canadian drug supply would be exhausted in 16 months with all the U.S. states trying to avail themselves of Canadian drugs,” she says.

Radar On Market Access: Pill Club, CVS Dispute Raises Larger Questions

September 5, 2019

CVS Health Corp.’s Caremark division came under fire recently when Pill Club, a birth-control-delivery startup, accused the PBM of restricting access to contraceptives amid a reimbursement dispute. The dustup even spilled onto social media, with the hashtags #CVSDeniesCare and #BoycottCVS trending on Twitter on Aug. 15.

CVS Health Corp.’s Caremark division came under fire recently when Pill Club, a birth-control-delivery startup, accused the PBM of restricting access to contraceptives amid a reimbursement dispute. The dustup even spilled onto social media, with the hashtags #CVSDeniesCare and #BoycottCVS trending on Twitter on Aug. 15.

While the dust has since settled, experts tell AIS Health that the incident raises bigger questions, including whether social media will increasingly be used by smaller fish in the pharmacy supply chain to amplify their negotiating clout with powerful PBMs.

The situation started when the PBM notified Pill Club and other non-traditional pharmacies that had been receiving reimbursements at the same rate as retail pharmacies that they would be subject to different terms, a CVS spokesperson told AIS Health.

Pill Club responded by calling out the company on a section of its website, which said that “CVS Caremark’s proposed payment changes threaten Pill Club’s ability to serve members.” CVS, in turn, created a section on its own website to dispute Pill Club’s claims, writing that it is “irresponsible for The Pill Club to falsely suggest access to women’s health care is being jeopardized just so it can maximize its profits at the expense of our PBM clients.”

Mariana Socal, M.D., assistant scientist at the Johns Hopkins Bloomberg School of Public Health’s Department of Health Policy and Management, says Pill Club was “trying to harness the power from social media and public interest” in order to boost its negotiation capabilities with CVS. “I believe that that’s an important resource that we may see more and more being tapped into by perhaps these online retailers and others,” she adds.

Radar On Market Access: Pediatric Managed Medicaid ACO Leverages Pharmacists to Improve Care

September 3, 2019

For a pediatric accountable care organization (ACO) that contracts with Ohio’s Medicaid managed care plans, improving care for children would be a much more difficult job without the expertise of pharmacists who understand the unique needs of those patients.

For a pediatric accountable care organization (ACO) that contracts with Ohio’s Medicaid managed care plans, improving care for children would be a much more difficult job without the expertise of pharmacists who understand the unique needs of those patients.

“Our MCO partners are often really well versed in the adult patient population and chronic diseases that afflict their adult patients — but sometimes the pediatric population’s chronic conditions are different,” Brigid Groves, a clinical pharmacist specializing in population health at Columbus-based Nationwide Children’s Hospital, tells AIS Health.

Groves is one of two pharmacists employed by Partners for Kids (PFK), the ACO affiliated with Nationwide Children’s Hospital that receives capitated payments from the state’s five MCOs to manage care for 330,000 children in central and southeastern Ohio.

As an example of how PFK pharmacists intervened to advocate for pediatric patients, Groves points to when the manufacturer of one type of inhaler shifted to a new, non-child-friendly delivery mechanism for the steroid that’s dispensed by the device.

“MCO plans were just kind of like, ‘great new product, put it on there’ [their formularies]. And it really impacted a lot of our kids because they weren’t able to get their steroid inhalers or use them appropriately,” she says. But PFK’s pharmacists explained the situation, and “our plans were then able to make appropriate changes on their formularies.”

One of the MCOs that contracts with PFK, CareSource, is currently making changes to how it covers the immunosuppressive drug Remicade (infliximab), and “we’ve worked with Partners for Kids pharmacists on our clinical criteria for prior authorization with pediatric use of that medication,” adds Nicholas Trego, Pharm.D., associate vice president of pharmacy for the insurer’s Ohio market.