New report finds the savings associated with the CPC initiative did not negate costs associated with care management. Learn more.

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May 25, 2018


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“You’re Going to Need a Bigger Boat”: CMMI Model Underwhelms


In a report issued to the Centers for Medicare & Medicaid Services (CMS) by Mathematica Policy Research this week, final analysis indicates that the Obama-era Comprehensive Primary Care Initiative (CPC), a 4-year effort that launched in 2012, fell short of expectations to reduce Medicare spending while improving patient health outcomes through incentivized physician outreach to patients and targeted health coaching for Medicare fee-for-service (FFS) recipients. Mathematica’s findings are summarized in a new Health Affairs article.

The CPC required participating practices, over 500 in total, to transform across 5 key care delivery functions: 1) access and continuity; 2) planned care for chronic conditions and preventive care; 3) risk-stratified care management; 4) patient and caregiver engagement; and 5) coordination of care across the medical neighborhood.

The report, the fourth and final review of the CPC, the foundation to the current Comprehensive Primary Care Plus (CPC+), found the frequency of hospitalizations and emergency room visits was reduced by 2% over the lifespan of the program for Medicare FFS beneficiaries at participating hospitals when compared to non-participants. However, despite a reduction in the fees associated with care for the beneficiaries, the savings did not negate the costs associated with care management.

Researchers found the largest areas of improvement were in risk-stratified care management, expanded access to care, and continuous improvement driven by data. Factors contributing to lackluster results were the burdens associated with quality monitoring and reporting for CMS and other payers, existing incentives in the FFS payment system that encourage volume of services over efficient use of services, and lack of infrastructure for comprehensive and efficient health information exchange between providers.

Still it seems the most significant way to shape how physicians interact with their patients for improved outcomes at a reduced cost to the Medicare program is to offer even more enhanced monetary incentives and an increase to performance-based bonuses.

  • On June 12, Health and Human Services (HHS) Secretary Alex Azar is scheduled to testify on President Trump’s Blueprint to Lower Drug Prices before the Senate Health, Education, Labor, and Pensions (HELP) Committee. 

On-Demand Webinar: The Emergence of Copay Accumulator Programs—Recent Research and Potential Impact on Patients


The Accumulator model presents new challenges to patients and manufacturers as it continues to gain traction in the marketplace.

Watch our on-demand webinar, featuring Xcenda’s Corey Ford, Director, Reimbursement Strategy & Tactics, and Lash Group’s Jim Dickey, Director, Product Experience, as they present exclusive research findings on copay Accumulator programs and their impact on manufacturers and patients.

Gain insights on:

  • Emerging trends in copay assistance
  • Research-based evidence on payer restrictions
  • Impact on patients and patient programs
  • Considerations for manufacturers


“You Got Any Better Suggestions?”: Congress Passes Right-to-Try Bill


On Tuesday, the House of Representatives passed a “right-to-try” bill, which is intended to help people with life-threatening conditions access experimental treatments outside of clinical trials. The House voted 250-169 on a version of the Trickett Wendler, Frank Mongiello, Jordan McLinn, and Matthew Bellina Right to Try Act of 2017 (S.204), which the Senate approved last August by unanimous consent. The bill is expected to be signed by President Trump soon.

Supporters of the bill asserted the Food and Drug Administration’s (FDA) expanded-access program for experimental medicines was too strict for many patients, even though the agency approves about 99% of requests. They insisted another pathway is needed for patients to obtain medications when they were unable to enroll in a clinical trial. However, many advocacy groups argue the measure will erode patient protections and place them at risk for harm from unproven and potentially unsafe therapies.

The bill is seen as a victory by President Trump, who pointedly mentioned it when introducing FDA Commissioner Scott Gottlieb at the rollout of his blueprint to lower drug prices.


Legislative Bytes


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The Tide Is With Us Today: Part D Analysis


This week, the Kaiser Family Foundation (KFF) released a brief based on data from CMS regarding 2018 Medicare Part D program enrollment, premiums, cost-sharing, and key trends. Here are some highlights.

Enrollment: In 2018, 43 million Medicare beneficiaries have prescription drug coverage under a Medicare Part D plan; 58% have a stand-alone prescription drug plan (PDP), but an increasing share (42%) are enrolled in a Medicare Advantage prescription drug plan (MA-PD plan). More than 12 million Part D beneficiaries qualify for premium and cost-sharing assistance through the Part D Low-Income Subsidy (LIS) program. In 2018, UnitedHealth, Humana, and CVS Health covered 55% of all beneficiaries enrolled in Part D plans (stand-alone PDPs and MA-PD plans) and 67% of all stand-alone PDP enrollees. UnitedHealth has the most MA-PD plan enrollees; CVS Health has the most PDP enrollees.

Premiums: PDP premiums have increased modestly in recent years. In 2018, the average PDP premium is $41 per month, up 2% from 2017 and up 11% since 2015. The average MA-PD plan premium in 2018 is $34, which includes Part D and other benefits. Premiums for many PDPs increased in 2018 and range from $20 per month for Humana Walmart Rx to $84 per month for AARP Medicare Rx Preferred.

Deductibles: About 45% of PDP and MA-PD plan enrollees are in plans that charge no deductible; however, a larger share of PDP enrollees are in plans charging the standard deductible amount of $405 in 2018.

Cost-Sharing: The majority of Part D enrollees will see minimal cost-sharing amounts for generic drugs but can see significantly higher cost-sharing for brand name and non-preferred drugs, and a variety of copayments and coinsurances for different formulary tiers. For preferred brand drugs, most PDP enrollees pay copayments of less than $40, and MA-PD plan enrollees typically pay between $45 and $47. For non-preferred drugs, 50% of PDP enrollees pay coinsurance of 40%–50%, while most MA-PD plan enrollees pay copayments between $90 and $100.

Specialty Drugs: 45% of PDP enrollees and 42% of MA-PD plan enrollees are in plans that charge the maximum 33% coinsurance rate for specialty drugs, defined by CMS as those that cost at least $670 per month.

This analysis highlighted concerns that many patient advocates have been raising for years: there is already a large concentration of Part D enrollees in a few plans, with 55% of enrollees belonging to 3 payers. The proposed mergers of CVS Health + Aetna and Cigna + Express Scripts would further consolidate the Part D marketplace, with 71% of all Part D enrollees and 86% of stand-alone drug plan enrollees belonging to those 4 firms. Secondly, cost-sharing for non-preferred and specialty drugs continues to increase, leading to concerns about patient access, particularly without a catastrophic cap in the program.


Not Going to Ignore This Until It Bites Us in the: MA Payment Reform Opportunities


This week, Duke University’s Margolis Center for Health Policy released a brief discussing Medicare Advantage’s (MA) current state and opportunities to implement and influence payment reform. With their commitment to shifting payments from FFS to alternative payment models (APMs) focusing on value, Medicare and Medicaid are paving the way.

Given their financial incentives and plan flexibility, MA plans are poised to do well in advancing APMs. However, challenges limit the amount of payment reform, such as provider participation variation and lack of plans sharing results or assessments.

The brief reviews a handful of MA APM projects, including results from a Humana project on value-based payment programs where the value-based program patients experienced improved outcomes in chronic condition care, screenings, and health outcome assessments compared to patients treated with FFS arrangements. Physicians in the test group also experienced higher quality-measure scores, and the total cost of care decreased by 15% compared to traditional FFS Medicare, and by 4% compared to FFS MA arrangements.

CMS has recently announced it will be making available new encounter data containing plan-reported utilization of inpatient, skilled nursing facility, home health, outpatient, carrier, and durable medical equipment services by beneficiaries for part of 2015, with plans to release the rest of the 2015 data later this year. The new data also include information on MA plans’ benefit packages, premiums, cost-sharing tiers, service areas, and Special Needs Plans.

These data, the Center argues, should be helpful in advancing APMs and other value-based payment arrangements; ultimately, time will tell if the encounter data do become available annually and have any impact on value-based reimbursement.


Not Just Local Jurisdiction: GAO Recommends CMS Continue Prior Auth Pilots


This week, the Government Accountability Office (GAO) released an evaluation of prior authorization (PA) pilot programs that CMS began in September 2012, and recommended the agency continue developing such programs as a potential to control unnecessary use of services and costs.

The 4 small-scale PA pilot programs in 7 states covered:

  • Repetitive scheduled non-emergency ambulance services
  • Home health services
  • Certain power mobility devices (eg, power wheelchairs)
  • Non-emergency hyperbaric oxygen therapy

CMS has also established a PA program for some durable medical equipment, prosthetics, orthotics, and supplies.

While these PA programs are either on hold or scheduled to end this year, GAO estimates that savings to the Medicare program ranged from $1.1 billion to $1.9 billion through March 2017. GAO does, however, provide these estimates with caution as it is difficult to identify which savings were completely attributed to these pilots vs other CMS efforts to cut costs. The report also acknowledged many providers and suppliers found PA to be effective in reducing unnecessary utilization and improper payments but found the documentation requirements challenging.

The report concluded CMS should continue its PA demonstration projects to avoid missing “opportunities for achieving its stated goal of reducing costs and realizing program savings.” HHS has yet to agree or disagree with these conclusions and is continuing to evaluate the programs, potentially expanding PA requirements to hospital beds and oxygen concentrators. While the agency has not stated PA for drugs is forthcoming, that option may be suggested as the Administration is ambitiously targeting the pharmaceutical industry.

While CMS may continue to experiment with PA programs, the private sector is expanding its use of PA policies, and while providers agree with the need to reduce unnecessary services, doctors still believe the PA process is cumbersome and places an unnecessary burden on their practices. In a recent survey from the American Medical Association, over 90% of physicians said the PA process affected clinical outcomes and 84% found the burden either high or extremely high. Provider offices complete an average of 30 PAs per week and spend nearly 15 hours working on them.


Information Buffet (AKA, Other Stuff That Caught Our Attention)


We kept running into stories we wanted to bring to your attention, so here’s a quick hit list of other news we thought you should know:

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Manufacturer Survey: Proactive Communication of HCEI


We want to hear from you.

We invite manufacturer partners to participate in a survey regarding policy impacts on proactive communication of healthcare economic information (HCEI). Participants will receive a copy of the survey results once available AND are eligible for a drawing for a pair of Apple AirPods!


“We are pleased that the President recently acknowledged the importance of requiring price disclosure on direct-to-consumer ads—it is our hope that he will actually follow through. As an honest first step to the American public, we urge you to immediately and voluntarily commit to transparency and disclose the price of your prescription drugs in direct-to-consumer advertisements.”

 – Five Democratic Senators (Dick Durbin [D-IL], Kirsten Gillibrand [D-NY], Maggie Hassan [D-NH], Sherrod Brown [D-OH], Angus King [I-ME]) sent letters to Pfizer, AbbVie, Bristol-Myers Squibb, Eli Lilly, Janssen, Merck, GlaxoSmithKline, and Novartis calling for transparency in advertising to consumers.

Source: “Durbin Calls for Transparency From Pharmaceutical Companies in Advertising to Consumers,” May 18



9.1% vs 9.0% vs 16.0%


In 2017, the percentage of persons of all ages who were uninsured was 9.1% (29.3 million), representing no significant change from the 2016 uninsured rate of 9.0% (28.6 million). A total of 19.3 million fewer persons lacked health insurance coverage in 2017 compared with 2010 (48.6 million or 16.0%).

Source: “Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, 2017,” National Center for Health Statistics (CDC), May 2018


2018 ASCO Annual Meeting

June 1–5 l Chicago, IL
AmerisourceBergen is proud to support this year’s ASCO Annual Meeting where more than 38,000 attendees from around the world gather to gain informative educational insights and listen to scientific sessions that highlight the latest in cancer care treatments. Visit AmerisourceBergen at booth #19135. Xcenda is also proud to co-author 2 posters presented at the event: Comprehensive tumor genomic testing in the community oncology setting in the United States (abstract #e24304) and Current real-world treatment patterns and outcomes in patients with relapsed/refractory multiple myeloma (abstract #e20038). Learn more


Count on Health Policy Weekly for an at-a-glance view of legislative and regulatory developments and news that impacts the healthcare industry.


Jennifer Snow
Senior Director,
Health Policy

Scott Shields
Associate Director,
Health Policy



Amy Grogg, PharmD
Senior Vice President | Strategy & Commercialization | AmerisourceBergen Corporation

Kristine Flemister, PharmD
President | Xcenda

Tommy Bramley, PhD, RPh
President | Lash Group

Stacie Heller
Vice President | Government Policy | AmerisourceBergen Corporation

Rita Norton
Senior Vice President | Government and Public Policy | AmerisourceBergen Corporation

Ana Stojanovska
Vice President | Reimbursement & Policy Insights | Xcenda


Amanda Forys | Maureen Holmes | Darren Jensen | Scott Shields | Diane Smith


Laurie Kozbelt | Ellen Olson


May 25, 2018


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