The DOJ issued a statement saying the Trump Administration wants to invalidate all of the ACA.

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Mar. 29, 2019

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Editor’s Note: We feel a little like we’re on a roller coaster, climbing up that first hill (can you hear the pull, the clickety-clack?) and about to hit free fall into a season of rules. As we steel ourselves, we thought we’d do a (mostly) catch-up issue on things you might have missed over the last few months.

 
FEATURED STORY
 

Trump Administration Now Supports Decision to Strike Down Entire ACA

 
 

On Monday, the Justice Department issued a statement siding with the Fifth Circuit US Court of Appeals decision to invalidate the Affordable Care Act (ACA) in its entirety—a much more draconian stance than the Administration has taken in the past.

In late December, a federal judge in Texas invalidated the entire ACA during the closing hours of 2019 healthcare marketplace (exchange) open enrollment. Invalidating the entire ACA encompasses a broad range of provisions, including Medicaid expansion, maintaining kids on their parents’ insurance until age 26, the biosimilars approval pathway, coverage gap payments by pharmaceutical manufacturers, the existence of the Center for Medicare and Medicaid Innovation (CMMI), calorie labeling, etc.

The plaintiffs, which included 20 Republican state attorneys general, had been hoping to strike down most of the law given invalidation of the individual mandate. The Trump Administration, at the time, did not agree that the entire ACA would have to be invalidated; however, they stated pre-existing condition protections and certain rating factors would be invalidated with repeal of the individual mandate. The ruling was a declaratory judgment and not an injunction to halt the ACA. The next stop for the ruling is the US Court of Appeals for the Fifth Circuit. If affirmed there, it will likely put the decision in the hands of the US Supreme Court (probably in 2020).

While the President has said, “If the Supreme Court rules that Obamacare is out, we’ll have a plan that is far better than Obamacare,” the hope for many members of Congress is that this gets resolved through the courts and the ACA remains (largely) intact. Republicans have yet to agree on a replacement bill despite years of repeal debates.

In related news, Medicaid work requirements and association health plans—2 goals of the Trump Administration that further undermined the ACA—were blocked in courts this week.

 

HPW Rebuild

 
XCENDA ORIGINAL RESEARCH
 

Playing Out the What-Ifs: ICER-Based Thresholds in Medicaid

 
 

The utilization of cost-effectiveness as the single barometer for the definition of value has severe implications for beneficiary access to medications. Following up on our work last year looking at how Medicare would change if it adopted Institute for Clinical and Economic Review (ICER)-based thresholds, Xcenda conducted an analysis examining the impact if Medicaid began using ICER-based formularies.

Our findings suggest a significant number of patients with multiple sclerosis (MS), rheumatoid arthritis (RA), non-small cell lung cancer (NSCLC), multiple myeloma, and psoriasis would lose access to the treatments their doctors determined were best for them if Medicaid relied on ICER-based formularies. For example, Xcenda research suggests that over 99% of prescriptions to treat MS would be switched and that 3/4 or more of prescriptions to treat RA, NSCLC, and psoriasis would have to be shifted to an ICER-recommended drug. In the balance of affordability and access, restricting physicians to a limited number of treatment options eliminates flexibility that is sometimes needed to treat patients on an individual basis; an ICER-based formulary ignores these clinical considerations.

 

A Problem That Keeps Growing: Accumulator Programs Update

 
 

Xcenda has been focused on the impact of copay accumulator adjustment programs on patients and patient-support programs. Copay accumulator programs exclude the use of manufacturer-sponsored copay assistance from a patient’s accrual of out-of-pocket expenses throughout a plan benefit year.

We recently conducted a survey of over 40 national and regional commercial payers to dig deeper on this trend. Nearly 60% of the payer respondents are targeting commercial copay assistance, up from roughly 40% from the same survey in 2018, and nearly all of these payers are employing some form of a copay accumulator program for products in select therapeutic areas.

In this issue brief, Rolling Back the Tide: Deploying a Consultative Approach to Tackle the Growing Expansion of Copay Accumulators, we examine the prevalence of these models in the commercial sector, employer decisions driving the uptake of these models, and possible solutions to address accumulators.

If you need more information on this or assistance with your patient-support strategy, please reach out to corey.ford@xcenda.com.

 

Medicare Part B: Do Providers Choose Treatment Based on Payment?
(Hint: They Don’t)

 
 

As the Administration considers drastic changes to the reimbursement and supply chain of Medicare Part B drugs, we were wondering if there was a problem to solve. What do Medicare claims data reveal about physician-administered drugs? Our study found no strong positive correlation between drug payment and utilization.

Check out our infographic to learn more.

View infographic >

 

Understanding Where We’re at to Help With Where We’re Going

 
 

At CBI’s Patient Assistance and Access Programs 2019 conference in Baltimore, Xcenda’s Jennifer Snow, MPH, Vice President of Reimbursement and Policy Insights, presented the “State of the Industry” session titled, “The Evolving Healthcare Landscape and the Impact on Patient Access and Affordability.” The slides are available here. Balancing access and affordability will not get easier, but having the discussions about how the spaces are changing is critical.

 
 

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

 
 
 
 
 
FEATURED CONTRIBUTORS
 

EDITOR-IN-CHIEF:
Jennifer Snow
Vice President,
Reimbursement and
Policy Insights,
Xcenda

MANAGING EDITOR:
Scott Shields
Associate Director,
Health Policy
Xcenda

 

ADVISORY BOARD:

Amy Grogg, PharmD
Senior Vice President | Commercialization Solutions | 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 | Commercial Consulting | Xcenda

CONTRIBUTING AUTHORS:

Corey Ford | Jennifer Snow

PRODUCTION:

Laurie Kozbelt | Ellen Olson

 

Mar. 29, 2019

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