This Week in Managed Care: April 26, 2019


This week, the top managed care news included HHS announcing 5 new primary care payment models; a judge blocking a "gag rule" for Title X; CMS reopening the rule for chimeric antigen receptor T-cell therapy add-on payments.

HHS offers 5 new primary care payment models, a federal judge blocks a so-called “gag rule” aimed at Planned Parenthood, and CMS reopens the rule for chimeric antigen receptor (CAR) T-cell therapy add-on payments.

Welcome to This Week in Managed Care. I’m Jaime Rosenberg.

HHS Announces 5 New Primary Care Payment Models

HHS joined with the American Medical Association (AMA) this week to announce 5 new primary care payment models to promote value-based care. HHS Secretary Alex Azar and CMS Administrator Seema Verma visited AMA headquarters to launch the voluntary initiative, called CMS Primary Cares. Some models give doctors a flat revenue stream to keep patients healthy and bonuses when they do well; other models allow doctors to take on more risk, but offer higher rewards.

Said Azar, JD: “This initiative is specifically designed to encourage state Medicaid programs and commercial payers to adopt similar approaches. [It’s] the pivotal, hockey stick moment in paying for value in American healthcare.”

The first models will begin in January 2020. AMA, a key stakeholder in developing the program, offered praise.

Said past Gerald E. Harmon, MD, immediate past chair, Board of Trustees, AMA: “Many primary care physicians have been struggling to deliver the care their patients need and to financially sustain their practices under current Medicare payments. The new primary care payment models…will provide practices with more resources and more flexibility to deliver the highest-quality care to their patients.”

For more visit

Federal Judge Will Issue Injunction in Title X Gag Rule Case

Elsewhere this week, AMA and the Trump administration were on opposing sides when a federal judge issued a temporary injunction over the Title X gag rule, which was due to take effect on May 3. The AMA is the lead plaintiff in the case.

US District Judge Michael J. McShane said he needed more time to determine whether the injunction will be nationwide or apply only to AMA and Planned Parenthood. In addition:

  • Judge McShane will address Trump administration requirements for physical and financial separation between Title X and non-Title X abortion-related services.
  • In his ruling, McShane emphasized that the original purpose of the Title X program was to provide family-planning services to low-income individuals, and that the new rule would compromise that goal.
  • McShane agreed with AMA's argument that the Title X program can reduce unintended pregnancies and lower rates of cervical cancer due to screening services.

CMS Proposes Increased Reimbursement for CAR T-Cell Therapy

A wide-ranging, 1800-page proposed rule issued this week reopens CMS’ technology add-on payment for CAR T-cell therapy. While the proposal calls for initially increasing the maximum add-on payment from $186,500 to $242,450, language in the rule suggests CMS is open to other ideas.

In a statement, CMS officials said: “These changes may help ensure adequate payments to hospitals administering this groundbreaking therapy while CMS continues our work to ensure that we pay for innovative therapies appropriately.”

The proposed boost in add-on payments comes as CMS weighs a separate plan that would require patients receiving CAR T-cell therapy to enroll in studies or registries, which would impose significant data gathering requirements on cancer centers that offer treatments. Some say what Medicare pays does not cover the cost of these requirements.

The CMS proposed rule includes:

  • Other changes to the technology add-on payment to promote innovation
  • Modernizing payment for breakthrough devices
  • Steps to improve quality and viability of rural health
  • Revising the definition of dual eligible
  • Update policies under the Inpatient Prospective Payment System and the Long-Term Care Hospital Prospective Payment System

For more, visit

Confirmatory Testing for Direct-to-Consumer Genetic Tests

As direct-to-consumer genetic tests become more popular, insurers and physicians are compelled to respond to patients who want to confirm results with a medical-grade test. The digital health company My Gene Counsel is addressing this gap by partnering with Ambry Genetics to help consumers by offering Living Lab Reports, which do the following:

  • Explain direct-to-consumer results
  • Discuss how these results may differ from a medical grade test from a genetic counselor or a provider
  • Offer a verification process that starts with understanding the family’s history of cancer
  • Have patients speak to a counselor by phone to decide if they need a verification test, which may be covered by insurance

Ellen Matloff, MS, CGC, president and chief executive officer of My Gene Counsel, told The American Journal of Managed Care® that many consumers don’t understand the limits of direct-to-consumer tests.

“Some consumers who need help based on strong personal or family history, instead of getting medical grade testing, they’re doing 23andMe and they’re using limited resources to pay for kits that won’t give them the answers they need,” she said.

Evidence-Based Oncology Discusses Adverse Events.

Finally, the current issue of Evidence-Based Oncology offers insights about adverse events: authors from Flatiron Health discuss a new tool for measuring them in clinical trials, and Sanjeet Dadwal, MD, of City of Hope asks whether antibiotics in the management of neutropenia are having unintended consequences.

The issue features full coverage from recent conferences.

For the full issue, visit

For all of us at the Managed Markets News Network, I’m Jaime Rosenberg. Thanks for joining us.

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