Category: Curator

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

Curator summary

Medicaid does not pay for the ancillary services most trial members need.

Clipped from: https://thehill.com/opinion/healthcare/523921-congress-can-and-should-improve-medicaid-enrollees-access-to-clinical

For many serious conditions, there are no proven therapies, so the best — and sometimes only — available treatment is an experimental therapy being tested in a clinical trial. My wife Kristin, for example, has been living with a type of cancer (metastatic ocular melanoma) that has both a poor prognosis and no proven treatment. Fortunately, she is enrolled in an open-label clinical trial — one where the participants know what treatment they are getting — of two drugs that are approved for other forms of cancer but are investigational for hers. 

Nearly two years into the trial, Kristin’s tumors, which had been growing rapidly, have stabilized, even shrunk a bit, and she is tolerating the treatment well. Her participation is possible only because our employer-provided health insurance covers the little-known but potentially prohibitive costs of the routine care that is required, but not paid for, by such trials. This routine care includes oncologist visits, lab tests, and scans to measure tumor progression. The drug company sponsoring the trial pays for the study drugs and the costs of running the trial. 

The Affordable Care Act (ACA) currently requires private health insurance to pay for the routine care associated with participation in clinical trials of treatments for cancer and other life-threatening conditions. The costs of routine care associated with participating in clinical trials for life-threatening conditions are also covered by Medicare, the federal health program for those 65 and older. 

That leaves two big groups uncovered: the uninsured, and enrollees in Medicaid, the federal-state program for low-income people, which covers one in five Americans. Providing health coverage to the uninsured — the primary aim of the ACA — remains an elusive goal, and the law continues to face court challenges. A prior Supreme Court ruling upheld provisions of the ACA, but this and other provisions of the law might not survive future court challenges. 

Fortunately, the lack of coverage by state Medicaid programs for the routine care required for clinical trial participation is a much more manageable problem than covering the uninsured. In fact, the Medicaid programs of 15 states and Washington, D.C., already cover these costs. Pending bipartisan federal legislation, the Clinical Treatment Act — which has a both House version (HR 913), and a Senate version (S. 4742) — would require all state Medicaid programs to cover these costs. Enactment of this legislation is crucial for two reasons. 

First, in the absence of the law, as many as 38 million Medicaid enrollees — a large portion of whom are from racial and ethnic minority and other underserved groups — are categorically blocked from receiving potentially lifesaving experimental treatments because their state’s Medicaid program does not cover the routine care that is required for trial participation. 

Medicaid enrollees tend to be low-income, underserved and vulnerable, and already face significant barriers to trial participation such as low health literacy, lack of trust in the health care system, and unmet logistical needs for trial participation such as lodging, meals, dependent care and transportation. Eliminating this significant financial roadblock to trial participation is an essential step to improve clinical trial access to Medicaid enrollees and reduce the health disparities that they experience.  

Second, people from racial and ethnic minority groups, low-income persons, and other underserved groups continue to be woefully underrepresented in therapeutic clinical trials. As a result, the knowledge gained from trials may be less applicable to members of these groups than to whites and to those with higher incomes. Passage of the Clinical Treatment Act will help to improve the relevance of the knowledge gained from clinical trials to these underserved groups, who often bear the heaviest burdens of cancer and other life-threatening illnesses. The COVID-19 pandemic has highlighted the critical need for diverse participation in therapeutic clinical trials by populations hit especially hard by the virus.

Kristin continues to do well, for now, in the trial of the experimental regimen that by all appearances seems to be prolonging her life. The scenario that we would have faced, if we instead had been covered by Medicaid and this experimental therapy had been unavailable, is simply unthinkable. The Clinical Treatment Act needs to be enacted without delay.

Sean Hennessy, PharmD, PhD, is a senior fellow at the Leonard Davis Institute of Health Economics and a professor of epidemiology at the University of Pennsylvania. Follow him on Twitter @HennessySean.

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

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KY MCO lawsuits continue, with latest development being court-ordered mediation.

Clipped from: https://www.bizjournals.com/louisville/news/2020/11/12/kentucky-medicaid-dispute-headed-toward-mediation.html

Getty Images / Maren Winter / EyeEm

The legal dispute surrounding the state’s Medicaid awards is headed to mediation.

On Thursday, Franklin County Circuit Judge Phillip Shepherd ordered the counsels for all parties involved in a lawsuit filed by Anthem Kentucky Managed Care Plan Inc. to seek approval to engage in mediation, select a mediator and choose days for mediation — all within the next 30 days.

Shepherd wrote that he would assign a mediator if the parties failed to agree on mediation or the selection of a mediator. He also expects a status report from the parties by the close of business Friday, Nov. 13.

In September, Anthem sued the state and the five Medicaid companies it awarded big-dollar Medicaid contracts to, alleging the state erred in the the awards process. Specifically, Anthem alleged in its suit that the state made scoring errors and failed to eliminate a bidder for the Medicaid contracts that inappropriately hired a former state official.

Anthem’s suit followed a failed administrative appeal over the contract awards.

In November 2019, the administration of then-Gov. Matt Bevin announced the five winners of an request for proposals for the Medicaid contracts after Bevin lost the election to now Gov. Andy Beshear, who rescinded the contracts in December 2019 and announced a new RFP process.

Ultimately, the Beshear administration announced the same RFP winners as the Bevin administration had.

Here are the companies that were twice awarded contracts by two different administrations. They are also named as defendants in Anthem’s lawsuit:

• Aetna Better Health of Kentucky
• Humana Health Plan Inc.
• WellCare Health Insurance of Kentucky
• Molina Healthcare of Kentucky
• UnitedHealthcare Community Plan of Kentucky

Shepherd also wrote in his Thursday order that he would consider a motion from UnitedHealthcare asking the court to assign it the members of Molina Healthcare and eliminate Molina from the Medicaid program and reverse a previous order that would allow Anthem to continue participating in the Medicaid program. UnitedHealthcare made that motion Nov. 2.

Timeline of court proceedings

On Oct. 23, Shepherd ordered the state to allow Anthem to continue in the Medicaid program, making it a sixth Medicaid company.

The managed-care organizations that won contracts and the state agencies claim in court documents that the judge overstepped his bounds. However, the state agencies complied with the order in an attempt to reduce disruption to the members in the Medicaid program.

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

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KY MCO contract protests continue, with UHC asking judge to invalidate Molina win and give lives that Anthem lost to UHC.

Clipped from: https://www.bizjournals.com/louisville/news/2020/11/11/unitedhealthcare-lobs-accusations-of-procurement-v.html

UnitedHealthcare of Kentucky Ltd. raises its own allegations of improper hiring of a government official in the legal controversy surrounding the state’s Medicaid contract awards.

One of the two incoming companies to the Kentucky Medicaid program made a bold ask in the legal dispute surrounding how the administration of Kentucky Gov. Andy Beshear awarded its five Medicaid contracts.

In Franklin Circuit Court, UnitedHealthcare of Kentucky Ltd. made a motion before Judge Philip Shepherd on Nov. 4 asking him to eliminate Anthem Kentucky Managed Care Plan Inc. and Molina Healthcare Inc. from participating in the Medicaid program and to reassign their members to UnitedHealthcare.

Specifically, the motion asks Shepherd to modify his Oct. 23 order to enjoin the Kentucky Cabinet for Health and Family Services (CHFS) to eliminate the Medicaid contract Molina Healthcare was awarded in May following an request for proposals process and to assign the members that are covered by Anthem, who did not prevail in the RFP, to UnitedHealthcare.

In his Oct. 23 order, Shepherd ordered the state to allow Anthem to continue participating in the Medicaid program. The order came as part of Anthem’s lawsuit against the state, filed in September, that came after it exhausted an administrative appeal.

Attorneys for the Beshear administration have said in court documents that the state will continue to include Anthem in the Medicaid program — despite claiming that Shepherd overstepped his bounds — to “ensure continuity of care in the Medicaid program and to prevent any potential disruption in the provision of services to Medicaid members.”

In November 2019, the administration of then-Gov. Matt Bevin announced the five winners of an RFP for the Medicaid contracts after Bevin lost the election to Beshear, who rescinded the contracts in December 2019 and announced a new RFP process.

Ultimately, the Beshear administration announced the same RFP winners as the Bevin administration did.

UnitedHealthcare won a contract in both RFPs, while Anthem did not win a contract in either.

Allegations of improper hiring

Anthem claimed in its appeal and lawsuit that the state erred in its scoring methods and for failing to eliminate a successful contract winner, Long Beach, California-based Molina Healthcare, over allegations of improperly hiring former Beshear CHFS transition team co-chair Emily Parento.

UnitedHealthcare argues that Shepherd’s order making Anthem a sixth Medicaid company violates state law and the terms of the state’s RFP. Further, the company argues that allowing Anthem to remain within the Medicaid program wouldn’t leave enough Medicaid members for UnitedHealthcare to run a viable business.

“UnitedHealthcare has been selected twice to serve the Medicaid population in Kentucky,” UnitedHealthcare spokeswoman Catherine Witz said in an email. “We respect the judge and his ruling, but we must ensure a fair and transparent procurement process.”

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

Curator summary

A move to apply rebates to combination drugs and discount cards to deductibles can have significant cost implications for states and members.

Clipped from: https://www.pennlive.com/opinion/2020/11/new-medicaid-proposal-will-put-treatments-and-cures-even-further-out-of-reach-opinion.html

President Trump has long promised to lower prescription drug prices. Unfortunately, two of his administration’s newest proposals would actually raise out-of-pocket costs and reduce access to medicines.

They must be scrapped before they do real harm.

Both proposals impact Medicaid, the joint federal-and-state program more than 60 million low-income Americans depend on for access to health care. Trump’s proposals would place a new and substantial burden on a group of Americans who least need added challenges: low-income individuals suffering from chronic diseases. Their access to the care they need is in serious jeopardy.

The first proposal involves a reclassification of combination drugs — those created by binding multiple drugs into one medication. Currently classified as new medications, they enter the market as a name brand with no generic competition. The proposed reclassification would deem them an alteration of an existing treatment — and Medicaid would accordingly demand that manufacturers provide the program the bigger rebates associated with that group of medications.

Patented new combination drugs are often made from two or more readily available generics. So cost-cutters naively say: why not just take the cheap generics separately if the clinical effect is the same? Therefore, the combination should cost no more. What they overlook is the complicated research questions underlying the creation of new combination medicines: which drugs can be effectively combined to treat which conditions at which dosages.

Once you know, for example, that combining generic Prilosec with baking soda can yield better results treating acid reflux in some patients, of course, it’s cheaper to take the two separately. But you never would have known about it were it not for extensive research and testing.

This proposed reclassification is the government trying to get away with paying less for costly innovation. It won’t work. Instead, it will hamper pharmaceutical research and development efforts. After all, companies won’t continue to pour millions of dollars into developing new and improved combination drugs if they have no reasonable financial incentive to do so. Combination therapies also make it much easier for patients to stick to their prescription regimens.

That can be a matter of life and death.

Combination treatments have done wonders extending the lives of patients with HIV and hepatitis. Instead of taking several different pills per day, with the risk of error that entails, a combination HIV or hepatitis medication allows patients to take just one pill to keep the disease at bay.

The second ill-considered Medicaid proposal could lead to new financial burdens for many low-income people. It would change the Medicaid rules on how co-pays and deductibles work.Medicaid enrollees typically have to meet a deductible each month — or other specified period, which varies by state — before the program starts paying for their medical care.

Meanwhile, pharmaceutical companies often issue discount coupons patients can use to meet part of or all of the costs of their medications. In Medicaid’s current structure, such coupons count toward meeting an enrollee’s deductible. Under the proposed change, the value of the coupons could be excluded from the deductible. If this change takes effect, enrollees will have a higher hurdle to jump before they begin to receive their benefits. That would pose major concerns for the many low-income Americans living with chronic conditions.

Right now, patients with a chronic disease already spend twice as much out-of-pocket on medications than patients without one. Those suffering from two chronic diseases are sometimes on the hook for nearly five times more. And conditions such as diabetes, obesity and high blood pressure are much more common at the lower income levels associated with Medicaid.

If this rule change goes forward, managing a chronic condition could soon become untenable. Indeed, cost is one of the primary reasons that half of all chronic disease medications aren’t taken as prescribed. When chronically ill people can’t afford their medicines, their conditions often drastically worsen. Stabilizing and treating them at that point can wind up costing much more.

Indeed, medication non-adherence leads to one in 10 U.S. hospitalizations and adds as much as $289 billion to national healthcare spending annually.These proposals for Medicaid will only make matters worse. The Trump administration should drop them.

Kenneth E. Thorpe is a professor of health policy at Emory University and chairman of the Partnership to Fight Chronic Disease.

New Roundtable, Curator, Finance

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

Curator summary

States are working on budgets that must be finalized this summer, and cuts to Medicaid and education appear likely in order to deal with a decrease in the tax revenue base.

Clipped from: https://www.marketwatch.com/story/medicaid-cuts-on-the-table-as-states-grapple-with-impact-of-pandemic-on-program-enrollment-01606494876

Administrator of the Centers for Medicare and Medicaid Services Seema Verma and Vice President Mike Pence look on as President Donald Trump speaks at a coronavirus briefing in April.

jim watson/Agence France-Presse/Getty Images

State leaders are weighing possible cuts to Medicaid services and health-care benefits to offset rising costs due to a surge of enrollees who have lost jobs and need health coverage as the coronavirus pandemic has intensified.

Congress boosted federal matching funds to states for Medicaid as part of its first coronavirus relief package, but many states are still struggling to afford the increasing pace of sign-ups in the program for low income and disabled people. Enrollment for the fiscal year ending Sept. 30, 2021, is expected to jump 8.2%, with state spending accelerating by 8.4%, compared with 6.3% growth in the previous fiscal year, based on data from 42 state Medicaid directors compiled by the Kaiser Family Foundation.

Medicaid has grown to become one of the largest portions of state budgets, from about 21% in fiscal 2008 to about 30% in fiscal 2018, according to the National Association of State Budget Officers.

State leaders working on budgets that must be finalized in July are confronting budget crises. Tax revenues have tumbled since March because of restrictions on businesses, social distancing and high unemployment related to the pandemic, economists have found. Most states have constitutional or statutory requirements that they maintain balanced budgets.

Some state leaders may try to narrow the gap between the revenues they need to balance the budget and the shortfalls they face by cutting vision and dental benefits, or payments to doctors and other providers. Cuts to other programs, such as education, could also be in the mix.