'Costs After Cancer Surgery Falling'

 Episode-of-care spending over 30 days after cancer-directed surgery significantly dropped among Medicare beneficiaries after shifting to more outpatient care, a cross-sectional study showed.

Among over 70,000 Medicare fee-for-service beneficiaries, inflation- and covariate-adjusted mean 30-day episode surgery expenditures decreased from $23,630 in 2011 to $20,239 in 2019, which corresponded to an annual change of -2.15% (95% CI -2.32 to -1.97), reported Anaeze C. Offodile II, MD, MPH, of the University of Texas MD Anderson Cancer Center in Houston, and colleagues.

When looking at specific settings, expenditures for outpatient surgery stayed relatively stable, with an annual change of 0.02% (95% CI -0.04 to 0.07), while adjusted episode spending on inpatient surgeries dropped from $31,964 in 2011 to $27,418 in 2019 (annual change -2.27%, 95% CI -2.43 to -2.12), the authors noted in a research letter published in JAMA Surgery.

"This overall decrease was largely attributable to lower spending associated with inpatient procedures and a concomitant increase in the proportion of surgeries performed in the less-expensive outpatient setting," Offodile and team wrote."These results have important implications for policy and clinical practice, particularly because the absolute number of patients with cancer aged 65 years or older is projected to nearly double from 52 million in 2018 to 95 million by 2060."

"The increasing use of minimally invasive approaches may have catalyzed the shift to outpatient surgery, while broad-based improvements in perioperative care (i.e., care standardization, implementation of enhanced recovery protocols, and multidisciplinary teams) may have led to reductions in surgical morbidity and mortality, contributing to the declines in 30-day episode spending for cancer-directed surgery," they added.

Over the study period, the proportion of outpatient surgeries jumped from 30.3% to 46.7% (annual change 1.95%, 95% CI 1.81-2.09).

"The main finding was surprising because overall healthcare costs have been increasing," co-author Alexander Melamed, MD, MPH, of Massachusetts General Hospital in Boston, told MedPage Today. "Important future work would seek to describe the mechanisms underlying the observed trends in expenditures to develop interventions and policies which may further increase the value of cancer care in the U.S."

Cancer is a disease of aging, and most cancer-related spending occurs among Medicare beneficiaries, the authors noted, with the current Baby Boomer population expected to pose a challenge for oncologists. Studies have predicted a 34% increase in cancer care spending, reaching $246 billion by the year 2030.

A large portion of spending occurs in the first year after patients are diagnosed with cancer, which is mostly attributed to cancer-directed surgery. Despite this, limited data are available on the trajectory of resource utilization linked to cancer-directed surgery for Medicare beneficiaries. Outpatient care may be a better option for Medicare patients, with a recent report from the HHS Office of Inspector General showing that one in four Medicare patients were harmed during hospital stays, and nearly half of these cases were preventable.

For this study, Offodile and colleagues examined data on 70,324 Medicare fee-for-service beneficiaries who underwent excisional or ablative surgery for cancer from January 2011 through December 2019. Surgery-related expenditures included all Medicare Part A claims -- hospitals, home health agencies, skilled nursing facilities, and hospice organizations -- in addition to Part B claims, including laboratories, healthcare practitioners, imaging, and durable medical equipment.

Using the Consumer Price Index for Medical Care, payments were adjusted for inflation to U.S. dollars in 2019. The researchers used one set of estimates to adjust for inflation expenditures, followed by a second set adjusted for demographics, type of cancer, dual eligibility, and comorbidities.

Median patient age was 74, and 64.5% were women. The most common cancer diagnoses were breast (37%), colorectal (15.1%), lung (9.3%), and prostate cancers (9.3%).

Offodile and team acknowledged that their results may not be generalizable to younger patients or those enrolled in Medicare Advantage programs.

Disclosures

Offodile reported receiving grants from Blue Cross Blue Shield, the Rising Tide Foundation for Clinical Cancer Research, the MD Anderson University Cancer Foundation, and the National Academy of Medicine, and receiving honoraria from the Indiana University and University of Tennessee departments of surgery.

Melamed reported receiving grants from the National Center for Advancing Translational Sciences, the National Cancer Institute, Conquer Cancer-The ASCO Foundation, and the National Academy of Medicine.

One co-author reported relationships with CMS, the National Cancer Institute, the Agency for Healthcare Research and Quality, Arnold Ventures, the Commonwealth Fund, and the Research Triangle Institute.

Primary Source

JAMA Surgery

Source Reference: Melamed A, et al "Trends in episode-of-care spending for cancer-directed surgery among US Medicare beneficiaries from 2011 to 2019" JAMA Surg 2022; DOI: 10.1001/jamasurg.2022.4493.

https://www.medpagetoday.com/surgery/generalsurgery/102111

Cost Savings With Pharmacist-Driven Substitutions of Oncology Biosimilars

 Use of biosimilars for cancer care increased at a network of community oncology practices following the implementation of a pharmacist-led biosimilar substitution program, and cost savings followed, a researcher reported here.

For four of the five agents evaluated, use of "preferred" biosimilars increased from about 75-90% before implementation of the program to above 90% for all four by the end of the study period, according to Jenny Li, PharmD, a clinical pharmacy services manager at the American Oncology Network (AON) in Texas, who presented the data in a poster presentation at the Midyear American Society of Health-System Pharmacists meeting.

Looking at the period from April 2021 to April 2022, payers saved $19 million before the program's implementation in October 2021, and $34 million thereafter. Providers saved $38 million and $72 million for the two periods, respectively.

"If the hurdle of trying to establish a program is what's stopping [people] from considering biosimilars, then hopefully projects like this, real-world data like this, will help convince other folks that it is possible," Li told MedPage Today.

The program assigned regional clinical pharmacists (RCPs) to various geographical areas that AON serves, to work with 107 physicians and 85 advanced practitioners at 76 locations, mostly small or independent practices operating outside large hospital systems. The RCPs would act as a liaison between providers, payers, administrators, and financial advisors to facilitate switches where possible and when cost-effective.

AON-preferred biosimilars were automatically embedded into provider's drug treatment regimens via their electronic health record (EHR) system. The pharmacists, financial teams, and providers would coordinate via the EHR to ascertain if patients' insurers would still cover the biosimilar, that the provider and patient were satisfied with the switch, and that the patient would actually save money. Switches were ultimately confirmed with provider approval.

About 20 biosimilars for cancer treatment exist. The five biosimilars they followed were for bevacizumab (Avastin), trastuzumab (Herceptin), rituximab (Rituxan), filgrastim (Neupogen), and pegfilgrastim (Neulasta). At the start of implementation to study end, approximate use of the preferred biosimilars increased by the following:

• Bevacizumab: 92% to 96%
• Trastuzumab: 88% to 94%
• Rituximab: 82% to 94%
• Filgrastim: 77% to 92%
• Pegfilgrastim: 45% to 68%

According to the poster, non-preferred pegfilgrastim use remains high due to patient and provider preference of the on-body delivery system, especially in clinics that serve patients living in rural areas.

Li said that introducing the RCPs relieves some of the pressure on providers to juggle financial logistics in selecting drugs that work well for their patients.

"In the past, our providers [would] get anywhere between 10 to 40 calls from the financial counselors letting them know, 'Hey, Doc, your drug that you just prescribed for this patient? Well the payer doesn't cover it.'" Li said. "So now our pharmacists are taking the burden away from the provider."

According to surveys, healthcare providers still remain hesitant to substitute biosimilars for nonmedical reasons, due to uncertainty about the efficacy and safety versus the reference product, or because of concerns about the switch affecting the relationship with their patients, among other reasons.

Another motivation for the program was keeping cancer patients close to home. Sometimes, Li said, a patient's experience is "going to be driving 3 hours to an academic center, and they don't know anybody, and they have to stay overnight" for treatment, she said. "Our focus is, let's not take the patient out of something that they're familiar with. Keep them in the community and support them through it as much as possible."

This is easier with extra support, like the RCPs, she said. "Oftentimes in these types of practices, they might not have the resource of the pharmacist."

The program launched in October 2021, and cost savings for the study were evaluated from April 1, 2021 to April 1, 2022. Barriers to making switches to AON-preferred biosimilars included patient assistance and compassionate drug programs, patient or provider preferences, and payer-specific biosimilar selection requirements. AON paused tracking of patient savings because there were too many confounders.

Disclosures

Part of the presentation was made possible through a medical education grant supported by Pfizer.

Li disclosed no conflicts of interest.

Primary Source

American Society of Health-System Pharmacists

Source Reference: Li J, et al "Biosimilar uptake and cost savings analysis before and after implementation of a pharmacist-driven substitution program within a national community oncology network" ASHP Midyear 2022; Abstract 4-044.

https://www.medpagetoday.com/meetingcoverage/ashp/102118

Pharmacies slam Cigna and Express Scripts for shrinking TRICARE network

 Cigna and its pharmacy benefit manager subsidiary Express Scripts should roll back a decision to shrink by 15,000 the pharmacy network for TRICARE, which offers coverage for active-duty military members, pharmacy groups say.

The groups wrote a letter to Cigna and Express Scripts leadership Tuesday (PDF) surrounding a decision to change the 50,000 facility pharmacy network for TRICARE beneficiaries. They were concerned that Cigna decided to end the contracts in late October as opposed to the end of the year, and there is widespread confusion over which pharmacies remain in-network. 

“Not only are patients scrambling, but there is a lot of confusion out there,” said Ronna Hauser, senior vice president of policy and pharmacy affairs at the National Community Pharmacists Association, in an interview with Fierce Healthcare. The group is one of several to sign on to the letter.

The groups wrote that Express Scripts sent out contract terms to independent pharmacies and some retail chains such as Kroger with rates below the cost of drugs. 

“Although a ‘new’ solicitation for the TRICARE pharmacy network was recently sent out, our members report that the contracts are virtually identical in terms of reimbursements to the ones sent out this summer,” the letter added.

The groups slammed Cigna’s decision to leave only one specialty pharmacy in-network: Express Scripts' sister company Accredo.

“The relationships between pharmacists and patients are built on trust, and for many patients is not something easily transferrable,” according to the letter, which included the National Association of Specialty Pharmacy and American Pharmacists Association among its signers. “Keeping patients’ trusted pharmacies in-network is critical to the patients’ care.”

Members of the groups have also complained that patients have reported missing doses and denials of sterile supplies needed to administer certain IV medications by Accredo. 

Express Scripts defended the move to Accredo, noting in a statement to Fierce Healthcare that it was a "best-in-class specialty pharmacy that supports patients living with complex health conditions."

The PBM added that less than 1% of TRICARE members need a specialty pharmacy and that most are already on Accredo. 

"We appreciate the continued feedback from industry organizations," the PBM said. "We take any concerns related to disruptions of care seriously, and if an issue does arise, we work swiftly with the patient and their doctor to address it.”

Lawmakers have criticized the decision by Cigna and Express Scripts to shrink their networks. Sen. Jon Tester, D-Montana, wrote a letter to the Department of Defense back in October outlining his concerns. Tester is chairman of the Senate Appropriations Committee’s defense subcommittee. 

Reps. Buddy Carter, R-Georgia, and Mike Rogers, R-Alabama, were also concerned about the impact of the specialty pharmacy changes on patient access. 

The letter is the latest in a long-running battle between PBMs and independent pharmacies and pharmacy groups. The pharmacies charge that PBMs and their insurer counterparts try to steer covered patients toward their own facilities. 

“This is a perfect example of the anti-competitive nature of the industry we have been trying to shed light on for years,” said Hauser. “There is a large amount of steering going on here … to mail order or retail pharmacy.”

https://www.fiercehealthcare.com/providers/pharmacies-slam-cigna-and-express-scripts-shrinking-tricare-network-15k

UnitedHealth report: As mental health concerns rise, more providers are available

 While mental health and substance abuse issues have only grown thanks to the pandemic, a bright spot may be forming: The number of providers available to treat these concerns is increasing, a new study shows.

The United Health Foundation, the philanthropic arm of insurance giant UnitedHealth Group, released its annual "America's Health Rankings" report and in the analysis found that between 2020 and 2021, the number of people who reported that their mental health was poor in 14 of the last 30 days increased by 11%.

In 2020, 13.2% reported frequent mental distress, and that rose to 14.7% in 2021, according to the report.

At the same time, drug-related deaths spiked. The report found that deaths increased by 20% nationwide between 2019 and 2020, reaching 27.9 deaths per 100,000. This the largest year-over-year increase in more than a decade, according to the report.

The report also found that disparities within drug deaths increased in tandem. Such deaths increased by 45% among multiracial populations and by 43% among Black populations. Drug-related deaths were highest among American Indian/Alaskan Native populations, occurring at a rate nine times higher than the lowest group, Asian patients.

However, the analysis found that the supply of mental health providers reached its highest levels since the report was first published in 2017. The number of mental health providers per 100,000 increased by 7% between 2021 and 2022 and has increased by 40% since the 2017 report.

There are now 305 mental health providers per 100,000, according to the report.

"The pandemic has impacted all of us in profound ways and at different times," said Rhonda Randall, M.D., executive vice president and chief medical officer at UnitedHealthcare Employer & Individual, in the press release. "We need to find ways to get those with substance abuse disorders the help they need. The increase we see in mental health providers is a promising sign, but we still have a long way to go."

Other findings in the report include:

• A spike the in premature death rate. The number of lives lost before age 75 increased by 18% between 2019 and 2020. Like with drug-related deaths, disparities also widened for this figure.
• Firearm-related deaths also increased. The rate of firearm deaths increased by 13% between 2019 and 2020.
• The prevalence of multiple chronic conditions is on the rise. Between 2020 and 2021, the number of people who had three or more chronic conditions—including arthritis, asthma, chronic kidney disease, chronic obstructive pulmonary disease, cardiovascular disease, cancer, depression and diabetes—increased by 5%. Many factors could have played a role, such as pandemic-driven care delays and greater risks for people who contracted COVID-19.
• Gains in insurance rates may be at risk. The uninsured rate decreased to 7% between 2019 and 2021, the report found. However, many of those people gained coverage thanks to flexibilities granted due to the pandemic, so there is a major chance that those gains could be reversed.
• Internet access is improving as telehealth use grows. The analysis found that high-speed internet access rose between 2019 and 2021 across all racial and ethnic groups.

Georges C. Benjamin, M.D., executive director of the American Public Health Association, said reports like this will become critical as the country grapples with public health crises in a post-COVID world.

"It’s clear that we as a nation have a health debt to pay—one that has accumulated over years," Benjamin said. "For too long, we have underinvested in our public health infrastructure and in the health of underserved communities of color where rates of chronic conditions and other health challenges are highest."

"We paid this debt during the pandemic, losing a million people, and we will continue to pay it over the coming years as we work to address the underlying racial and ethnic and other inequities that COVID-19 highlighted and exacerbated," he said.

https://www.fiercehealthcare.com/providers/unitedhealth-report-mental-health-concerns-rise-more-providers-are-available-treat-these

With costly discharge bottlenecks, hospitals want Congress to pay for patients' extended stays

 The hospital lobby is looking to secure temporary per diem Medicare payments from Congress it says are needed to offset increased costs and missed revenues caused by patients who are ready to leave the hospital but have nowhere to go.

Per a new report (PDF) from the American Hospital Association (AHA), the average hospital length-of-stay has increased by 19.2% from 2019 to 2022 as well as by nearly 24% for patients being discharged to a post-acute care provider.

That increase isn’t just due to patients getting sicker during the course of the pandemic. When adjusting by case-mix index, average length-of-stay was still up 15.4% for discharges to post-acute care providers. Adjusted average stays were even higher when discharging to a skilled nursing facility (20.2%) or a psychiatric hospital (28.9%), according to data from Strata Decision Technology cited in AHA’s report.

Rather, acute care hospitals, long-term care hospitals and rehabilitation facilities alike are facing discharge logjams due to industrywide workforce shortages. Post-acute care facilities in need of more hands have been forced to limit their capacity and new patient transfers, which AHA said places “incredible strain” on hospitals, further wears down staff and threatens patient recovery.

“Delays in patient discharges create bottlenecks in the healthcare system, adding to the already overwhelming challenges facing our hospitals and caregivers,” AHA president and CEO Rick Pollack said in a release accompanying the report. “Temporary relief to overburdened hospitals and other providers will help ensure patients get the most appropriate care and will relieve stress on front-line healthcare workers.”

AHA wrote in the report that hospitals have been “left to bear the burden” of caring for stranded patients while noting that the organizations don’t currently receive any additional reimbursement for extra days spent in a hospital bed.

The group’s solution to the issue—alongside its other policy asks during the lame duck session—is a temporary per diem Medicare payment targeting acute, long-term care, rehabilitation and psychiatric hospitals.

“This per diem payment would be made for cases identified and assigned with a specific discharge code that fall under such type of long stays where the patient is documented to be ready for discharge but is unable to be discharged appropriately,” AHA wrote in its report. “The solution could be modeled after an existing per diem Medicare payment mechanism and be temporary with a cap on payments.”

Labor and discharge challenges have been constants throughout the pandemic, often reaching a head during periods with intense local or national surges of COVID-19.

Hospitals and health systems have underscored recent lobbying efforts with consistent messaging on a $135 million projected year-over-year increase in nationwide costs and potential service shutdowns. Just last week, the Texas Hospital Association warned that more than a quarter of its rural hospitals are at risk of closure.

That said, the pain hasn’t been felt evenly across the nation’s health systems. Though October ushered in the industry’s tenth consecutive month of negative margins, a recent Kaiser Family Foundation report found that operating margins for the country’s three largest for-profit health systems have surged over their pre-pandemic numbers.

https://www.fiercehealthcare.com/providers/downstream-capacity-issues-keep-patients-waiting-discharges-hospitals-wants-congress-pay

Urban: 18M could lose Medicaid coverage after COVID-19 emergency expires

 A new estimate finds that 18 million people could lose Medicaid coverage after the COVID-19 public health emergency ends, with 4 million becoming uninsured. 

The analysis, conducted by the Urban Institute and released Monday, underscores the obstacles states and the federal government will face when the PHE ends and states must redetermine eligibility for those on Medicaid.

“We anticipate that the end of the PHE will cause the biggest changes in coverage since implementation of the Affordable Care Act more than a decade ago,” said Katherine Hempstead, senior policy advisor for the Robert Wood Johnson Foundation, which supported the study. 

The report is the latest to detail the ramifications of the end of the PHE. Urban’s 18 million estimate is slightly above the 15 million the Department of Health and Human Services predicted will lose coverage. 

The number of coverage losses is likely to continue to go up as long as the PHE persists and more people join Medicaid.

"This reflects the underlying dynamic of the PHE itself—enrollment keeps happening, but disenrollment does not,” said Hempstead in an email to Fierce Healthcare. “Normally, there is an inflow and outflow of members in every state’s Medicaid program as people gain and lose eligibility, even if net enrollment may grow or decline over time, but during the PHE the outflow is not taking place at anything like the normal level.”

At the start of the pandemic, the federal government raised the matching rate for Medicaid payments if the state agreed to not drop anyone off Medicaid’s rolls for the duration of the PHE. The emergency currently runs through January but is likely to be extended for another 90 days. 

States have been preparing for months for the start of redeterminations, with some believing it could take at least a year to finish the task.

Urban relied on the latest Medicaid enrollment data as well as survey data on health coverage. 

If the PHE ends in April 2023, 18 million people will drop off Medicaid over the next 14 months, the report said. Most of those people will transition to other insurance sources, with about 3.8 million people becoming uninsured. 

It found that about 9.5 million people will get employer-sponsored care and more than 1 million will get Affordable Care Act coverage. Another 3.2 million children are also estimated to transition to the Children’s Health Insurance Program. 

Researchers considered state policy issues that may affect the transition. 

“First, some states could process enrollment more rapidly than others,” the report said. “The loss of the enhanced [federal matching Medicaid rate] in the quarter following the PHE expiration provides a financial incentive to do so.”

A faster redetermination process could result in millions more people losing coverage right after the PHE ends.

Centers for Medicare & Medicaid Services Administrator Chiquita Brooks-LaSure has said coordination between states and the Affordable Care Act exchanges will also be pivotal to ensure people can get coverage via a special enrollment period.

https://www.fiercehealthcare.com/payers/urban-18m-could-lose-medicaid-coverage-after-covid-19-emergency-expires-likely-next-year

UnitedHealth, LHC Group extend merger agreement as FTC probe continues

 LHC Group and UnitedHealth Group have extended their merger agreement as the feds take a deeper look at the deal.

The agreement was extended until March 28, 2023, and the two companies now expect the merger to close in the first quarter of 2023, according to a filing with the Securities and Exchange Commission.

That the insurance giant intended to acquire LHC, a home health provider, was announced in March, and the deal is valued at about $5.4 billion. UnitedHealth said it plans to fold LHC into its Optum subsidiary as part of its provider arm, Optum Health, which is one of the country's largest employers of physicians.

LHC Group would add 30,000 employees who provide more than 12 million home health services annually.

The Federal Trade Commission (FTC) issued a second request for information in June on the deal. In the filing, LHC Group said that both companies have certified "substantial compliance" with the FTC.

The ongoing FTC probe is the second major issue that the companies have encountered on the path to closing this merger. An LHC shareholder sued the company in May, arguing LHC withheld key details in its documents recommending shareholders approve the sale to UnitedHealth.

It's also the second major acquisition by UHG that's run into concern from federal regulators. The Department of Justice (DOJ) sued to block the company's purchase of Change Healthcare, though UnitedHealth prevailed in court as a federal judge allowed the merger to move forward.

DOJ is planning an appeal, though that challenge would now pit it against a closed deal and companies that have begun integration.

https://www.fiercehealthcare.com/payers/unitedhealth-lhc-group-extend-merger-agreement-ftc-probe-continues