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MMIT Reality Check on Crohn’s Disease (Nov 2019)

November 29, 2019

According to our recent payer coverage analysis for Crohn’s disease treatments, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

According to our recent payer coverage analysis for Crohn’s disease 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 Crohn’s disease treatments shows that under the pharmacy benefit, almost 58% of the lives under commercial formularies are covered with utilization management restrictions.

Trends: In July 2019, the FDA approved Samsung Bioepis Co., Ltd.’s Hadlima (adalimumab-bwwd) for the treatment of rheumatoid arthritis, juvenile idiopathic arthritis, psoriatic arthritis, ankylosing spondylitis, adult Crohn’s disease, ulcerative colitis and plaque psoriasis. Merck & Co., Inc. will commercialize the drug in the U.S. It is expected to launch after June 30, 2023.

Perspectives on Racial Bias in Optum Risk-Prediction Algorithm

November 28, 2019

To improve care for patients with the most complex health needs, many providers and payers turn to risk-prediction tools that use an algorithm to determine which patients need more intense care management. But a recent study, published in the journal Science, found that one such widely used algorithm exhibits significant racial bias by assigning black patients the same level of risk as white patients even when they are far sicker, AIS Health reported.

To improve care for patients with the most complex health needs, many providers and payers turn to risk-prediction tools that use an algorithm to determine which patients need more intense care management. But a recent study, published in the journal Science, found that one such widely used algorithm exhibits significant racial bias by assigning black patients the same level of risk as white patients even when they are far sicker, AIS Health reported.

This study garnered significant media attention, and at least one state’s regulators launched an investigation into UnitedHealth Group, whose Optum subsidiary sells Impact Pro, the data analytics program that researchers studied.

Brian Powers, M.D., one of the study’s authors and a researcher at Brigham and Women’s Hospital, says that “the algorithm did a great job of what it was specifically designed to do, which was predict future health care costs.” The problem is that the organizations deploying the tool often “use health care costs as a proxy for health care need,” he says, and black patients tend to cost the health system less because of a “lack of access to care due to structural inequalities, and a variety of other issues that have been well documented.” So while there is a correlation between high-risk patients and high health care spending, just looking at expenditures doesn’t paint a truly accurate picture of patients’ health care needs.

Rich Caruana, a Microsoft Corp. senior researcher who studies machine learning in health care, says he was “not at all surprised” to learn that researchers uncovered hidden bias in a predictive algorithm.

“Most of what machine learning is doing is right, but in addition to these things it’s doing really right, roughly 5% of what it’s learning are these sort of silly, wrong things,” he continues. “These are known as treatment effects — we’re seeing patients’ risk as more or less based on the treatment that they receive.”

Radar On Market Access: Trump Administration’s Transparency Rules Are Part of Larger Effort

November 28, 2019

On Nov. 15, the Trump administration released two rules — one final, one proposed — outlining new price transparency requirements for hospitals and health insurers, which the industry has long warned will impede competitive rate negotiations without actually benefiting patients, AIS Health reported.

On Nov. 15, the Trump administration released two rules — one final, one proposed — outlining new price transparency requirements for hospitals and health insurers, which the industry has long warned will impede competitive rate negotiations without actually benefiting patients, AIS Health reported.

In the proposed rule, slated for publication in the Nov. 27 Federal Register, the administration would require all non-grandfathered group and individual health plans to:

  • Provide consumers with personalized out-of-pocket cost information for all covered health care items and services through an “internet-based self-service tool” and in paper form upon request, and
  • Make their negotiated rates with in-network providers and historical allowed amounts to out-of-network providers available to the public in “standardized, regularly updated machine-readable files.”

In a simultaneously issued final rule, the administration outlines transparency requirements for hospitals. It says they must make public, in a machine-readable format, all “standard charges” for items and services — which the rule defines as gross charges, payer-specific negotiated charges, de-identified minimum and maximum negotiated charges, and discounted cash prices. Plus, hospitals will have to publicly post standard charges for at least 300 “shoppable services” in a consumer-friendly format.

Previously, “standard charges” simply meant hospital chargemaster prices, explains David Kaufman, a partner at Laurus Law Group LLC and former general counsel of Blue Cross Blue Shield of Illinois. Whether CMS is allowed to expand that to include negotiated rates is “going to be the key issue” in a court challenge that hospital groups have promised to file, he tells AIS Health.

But while legal challenges could delay or even prevent one or both rules from being implemented, that doesn’t mean health care organizations have nothing to worry about, says attorney Katie Keith, a principal at Keith Policy Solutions, LLC.

“I guess if I was in the industry, I wouldn’t have my head in the sand about this,” she says. “Insurance companies, to the extent that they have not developed these tools and are not working on this and are not focused on transparency, it does seem like they’re going to want to increase focus on it, because I don’t know that every lawsuit will be successful.”

Radar On Market Access: National and Regional Players Make Dual Eligible SNP Moves

November 26, 2019

Through strategic acquisitions, product launches and geographic expansions, Medicare Advantage insurers across the U.S. are offering new Special Needs Plans (SNPs) aimed at improving the lives of members who are dually eligible for Medicare and Medicaid, AIS Health reported.

Through strategic acquisitions, product launches and geographic expansions, Medicare Advantage insurers across the U.S. are offering new Special Needs Plans (SNPs) aimed at improving the lives of members who are dually eligible for Medicare and Medicaid, AIS Health reported.

According to an analysis of the 2020 “landscape” files posted by CMS in September, Chicago health care consultancy Clear View Solutions, LLC, estimates that there are 171 net new SNP IDs, up from 60 net new plans in 2019. And 97 of those net new plans are dual eligible SNPs, compared with 47 D-SNPs that were introduced for 2019.

“I do think there is some ‘pent up energy’ from plans, and now that there is clarity with permanency and the requirements for integration, plans are ready to move forward,” Cheryl Phillips, M.D., CEO of the SNP Alliance, says in an email to AIS Health.

Phillips says plans may also be “working to better position themselves” for managed long-term services and supports, as states sharpen their focus on rebalancing their long-term care populations and shift more of the responsibility to managed care organizations.

A review of the new D-SNP offerings for 2020 indicates that larger players such as Anthem, Inc., Centene Corp., Humana Inc., Molina Healthcare, Inc. and UnitedHealthcare are leading the charge, but numerous plans have been introduced on a local level.

For instance, UCare, the largest provider of SNPs in Minnesota, said it is expanding its UCare Connect + Medicare plans to mirror the 62-county UCare Connect service area. And Priority Health is preparing to launch its first D-SNP, which will serve all 68 counties of Michigan’s lower peninsula.

MMIT Reality Check on Atopic Dermatitis (Nov 2019)

November 22, 2019

According to our recent payer coverage analysis for atopic dermatitis treatments, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

According to our recent payer coverage analysis for atopic dermatitis 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 atopic dermatitis treatments shows that under the pharmacy benefit, about 26% of the lives under commercial formularies are covered with utilization management restrictions.

Trends: In March 2019, the FDA expanded the approval of Dupixent (dupilumab) to treat moderate-to-severe atopic dermatitis in people aged 12 to 17 years whose disease is not adequately controlled with topical prescription therapies or when those treatments are not advisable.