Med­i­caid man­agers seek ways to pay for spe­cialty drugs

Modern Healthcare - - THE WEEK AHEAD - —Vir­gil Dick­son

Med­i­caid man­aged-care plan op­er­a­tors are look­ing for a way to pay for high-priced spe­cialty drugs such as So­valdi and Har­voni, the $1,000-per-pill treat­ments ap­proved by the Food and Drug Ad­min­is­tra­tion to treat hep­ati­tis C.

The Med­i­caid Health Plans of Amer­ica also will be look­ing to put a hu­man face on their op­er­a­tions when they hold their an­nual con­fer­ence in Wash­ing­ton this week. With more states mov­ing Med­i­caid ben­e­fi­cia­ries into man­aged-care or­ga­ni­za­tions, and Med­i­caid rolls in over half the states grow­ing thanks to the Pa­tient Pro­tec­tion and Af­ford­able Act, the na­tional trade group plans to high­light per­sonal anec­dotes from cus­tomers. One plan has pre­pared an emo­tional story about how it pro­vided high-qual­ity care for 9-year-old Ju­lia Lin­den­muth, who has a de­bil­i­tat­ing dis­ease.

En­roll­ment of Med­i­caid and Chil­dren’s Health In­surance Pro­gram ben­e­fi­cia­ries in man­aged care will in­crease by 13.5 mil­lion by 2016, ac­cord­ing to con­sult­ing firm Avalere Health. That will bring to­tal man­aged-care en­roll­ment to 76% of all Med­i­caid and CHIP en­rollees, up from 67% in 2013.

But the bot­tom-line is­sue on the con­fer­ence agenda fo­cuses on the bud­getary pres­sures fac­ing state gov­ern­ments be­cause of high-priced hep­ati­tis C drugs. At­ten­dees can learn best prac­tices in pre-treat­ment as­sess­ment, the im­por­tance of mon­i­tor­ing al­co­hol and weight, psy­cho-so­cial el­e­ments, post-treat­ment strate­gies and how to com­mu­ni­cate the dan­gers of not fol­low­ing a post-treat­ment pro­to­col.

The con­cern: Once the $100,000 reg­i­mens are ap­proved, pa­tients need to stick with them. Some states have im­ple­mented a “once in a lifetime” rule for So­valdi. Sim­i­lar poli­cies are ex­pected for newly re­leased Har­voni.

The con­fer­ence also will fea­ture ses­sions on pa­tient en­gage­ment. The aim is to teach plan man­agers how to struc­ture mem­ber en­gage­ment and in­cen­tive pro­grams so they pro­duce the de­sired be­hav­ioral changes and a re­turn on the in­vest­ment.

Ju­lia Lin­den­muth

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