MSSNY eNews – MSSNY Partners: “No to CVS-Aetna!”
Thomas J. Madejski, MD
August 10, 2018
Volume 20 Number 29
I am happy to report that MSSNY now has partners in our opposition to the proposed CVS takeover of Aetna.
Earlier this year Immediate MSSNY Past President Dr. Charles Rothberg wrote to the New York Attorney General’s office and to the NY DFS to express our very serious concerns with this merger of health care behemoths. He also testified at an Assembly hearing in June examining the impact of this merger proposal where he shared our numerous concerns.
These concerns include the possibility of reduced community pharmacy options, increased prior authorization burdens, a reduction in health insurer competition, and the proliferation of corporate owned retail clinics. Our statements about these concerns were reported in several media publications.
AMA and California Insurance Commissioner Agree with MSSNY
Last week, the California Insurance Commissioner submitted a letter urging the US Department of Justice to block the merger because of the potentially “significant anti-competitive impacts on consumers and health care and health insurance markets”. Commissioner Jones found that the proposed merger poses competitive concerns in the Medicare Part D market, where both companies currently compete, as well as in the highly-concentrated market for PBM services, and in the retail pharmacy market. This followed a June public hearing where the California Medical Association, the AMA and several legal professors raised serious concerns.
And this week the AMA released its own comprehensive analysis that was sent to the DOJ that also urged the DOJ to work to block the merger. Earlier this year, the AMA had submitted testimony to the US House Judiciary Committee raising similar concerns.
MSSNY has shared these analyses with the NYS DFS. However, it is unknown whether DFS will make a similar request to the DOJ. No hearing has been planned as of yet. However, a few weeks back, Superintendent Vullo was quoted in Politico-NY about her concerns with this proposed merger. The Pharmacists Society of the State of NY has also urged action by regulators to reject this merger.
We are hopeful New York will view this merger in the same concerning way that California has. Stay tuned for further updates.
NY DFS Announces Increased 2019 Premium Rates for Insurance Plans
Far Less than Requested by Insurers
The New York Department of Financial Services recently announced that the approved premiums for individual and small group health insurance plans for the 2019 policy year will increase by an average of 4.8% for 2019, an amount that was far less than what was proposed by health insurers. To read the full press release, click here.
For the individual market, DFS noted that it reduced the insurers’ total average requested increase from 24% to 8.6%. Notably, DFS reduced a 38.6% requested increase by Fidelis to 13.7%; a 23.6% requested increase by United to 1.5%;and rejected entirely a 24% requested increase by Empire.
For the small group market, DFS noted it reduced the insurers’ total average requested increase from 7.5% to 3.8%. Notably, DFS reduced a16.2% requested increase by Aetna to 7.9%; an 8.3% from Oxford to 3%; and 7.2% requested increase by United to a 1% decrease.
CMS Proposes to Permit “Step Therapy” for Part B Drugs in Medicare
This week the Centers for Medicare & Medicaid Services (CMS) issued a guidance that will permit Medicare Advantage (MA) plans, beginning January 1, 2019, to have the option to implement “step therapy” to manage a patient’s use of medications covered by Medicare Part B. Step therapy is a form of prior authorization whereby an insurer can make a patient “fail first” on alternative medication before the preferred medication is permitted to be covered by the insurer.
In its press release, CMS notes that MA plans will still be required to cover all medically necessary Part B drugs for beneficiaries. The beneficiary can ask the MA plan for an exception if they believe they need direct access to a drug that would otherwise only be available after trying an alternative drug. The press release also notes that step therapy can only be applied to new prescriptions or administrations of Part B drugs for patients that are not actively receiving the affected medication, so that MA plans cannot disrupt ongoing Part B drug therapies for patients.
The guidance further provides that a patient subject to step therapy can ask the MA plan for an expedited exception if they believe they need direct access to a drug that would otherwise only be available after trying an alternative drug. Exception requests will be completed as expeditiously as the beneficiary’s health condition requires, generally within 72-hours. Furthermore, the release notes that, if a plan denies a beneficiary’s request, the beneficiary has the right to appeal and CMS will be monitoring appeals activity to ensure beneficiaries’ requests are appropriately evaluated.
MSSNY will be working with the AMA and other state medical societies to assure that there are necessary patient protections for step therapy use that are at least as favorable for patients as the law that passed in New York in 2016 applicable to patients enrolled in commercial and Medicaid managed care plans. MSSNY advocated forcefully for this law together with other specialty societies and patient advocacy groups.
AMA President Dr. Barbara McEneny issued the following statement:
“The AMA has serious concerns about the Administration’s guidance to allow Medicare Advantage plans to use step therapy. Physicians are concerned with patients getting the most effective treatment, and step therapy requirements frequently get in the way. Patients who already are subject to step therapy requirements must contend with denials for medications from health plans. Physicians have no easy access to patient benefit and formulary information at the point of prescribing, so they will not be able to readily determine which drugs are preferred by their patients’ MA plans. This results in treatment delays and unnecessary red tape for physicians and patients.”
CMS Proposes Significant Restructuring of Medicare ACO Program to Increase Risk-Bearing
This week the Centers for Medicare & Medicaid Services (CMS) proposed a rule to significantly restructure the existing Medicare Accountable Care Organizations (ACO) program with the goal to “transition to two-sided models (in which they may share in savings and are accountable for repaying shared losses).” CMS projects the proposed rule would produce $2.24 billion in federal savings over 10 years.
In announcing the proposed rule, CMS Administrator Seema Verma noted that “the time has come to put real ‘accountability’ in Accountable Care Organizations. Medicare cannot afford to support programs with weak incentives that do not deliver value,” adding that “most Medicare ACOs do not currently face any financial consequences when costs go up, and this has to change.”
The proposed rule would eliminate the existing Tracks 1 and 2 in the program and instead establish a new “BASIC track” allowing ACOs to “gain experience with more modest levels of performance-based risk on their way to accepting greater levels of performance-based risk over time.” The current Track 3 would be renamed the “ENHANCED” track which will have higher levels of potential risk and reward. More experienced ACOs would be limited to “higher-risk participation options,” and CMS would conduct more rigorous screening of certain ACOs.
CMS proposes to provide a 6-month extension for ACOs with agreements expiring in 2018, and a “special one-time July 1, 2019 start date that will have a spring 2019 application period for the new participation options.”
To read the CMS press release and additional information, click here.
To read CMS Administrator Verma’s justification for the program in Health Affairs, click here.
Effective Immediately: Marijuana Can Be Prescribed for Chronic Pain
On July 12, the New York State Department of Health announced the filing of emergency regulations adding any condition for which an opioid could be prescribed as a qualifying condition for medical marijuana. Effective immediately, registered practitioners may certify patients to use medical marijuana as a replacement for opioids, provided that the precise underlying condition for which an opioid would otherwise be prescribed is stated on the patient’s certification. This allows patients with severe pain that doesn’t meet the definition of chronic pain to use medical marijuana as a replacement for opioids.
In addition, the regulation adds opioid use disorder as an associated condition. This allows patients with opioid use disorder who are enrolled in a certified treatment program to use medical marijuana as an opioid replacement.
Plans to add opioid replacement as a qualifying condition for medical marijuana were first announced last month.
As of June 18, 2018, there are 59,327 certified patients and 1,697 registered practitioners participating in the program.
Opioid replacement joins the following 12 qualifying conditions under the state’s Medical Marijuana Program: cancer; HIV infection or AIDS; amyotrophic lateral sclerosis (ALS); Parkinson’s disease; multiple sclerosis; spinal cord injury with spasticity; epilepsy; inflammatory bowel disease; neuropathy; Huntington’s disease; post-traumatic stress disorder; and chronic pain.
The permanent regulations were published in the New York State Register on August 1, 2018, and will be subject to a 60-day public comment period.
In addition, certified patients and designated caregivers will be able to print temporary registry ID cards. (See notice below). This will allow them to purchase medical marijuana products more quickly after registering for the program. Patients may use the temporary registry ID card in conjunction with a government issued photo identification to purchase medical marijuana products from a registered organization’s dispensing facility. Prior to this enhancement to the Medical Marijuana Data Management System, it could take 7 to 10 days for patients and their caregivers to receive their registry identification cards after their registration was approved.
Other recent enhancements to New York’s Medical Marijuana Program include adopting new regulations to improve the program for patients, practitioners and registered organizations; authorizing five additional registered organizations to manufacture and dispense medical marijuana; adding chronic pain and PTSD as qualifying conditions; permitting home delivery; and empowering nurse practitioners and physician assistants to certify patients.
As of July 10, 2018, there are 62,256 certified patients and 1,735 registered practitioners participating in the program.
For more information on New York’s Medical Marijuana Program, go here.
The following is the public list for physicians registered with the medical marijuana program:
Emergency Medical Marijuana Regulations Effective Immediately
Temporary ID Cards will be available for certified patients to purchase products more quickly. Certified patients and designated prescribers will be able to print temporary registry ID cards.
DOH: Please Answer Survey re Social Determinants of Health Assessment Tool
The New York State Department of Health, Office of Health Insurance Programs, Bureau of Social Determinants of Health, is asking stakeholders to fill out this quick ten question survey regarding the creation and use of social determinants of health (SDH) assessment tool. A SDH assessment tool is defined as a survey or questionnaire that is administered to patients/clients/members to assess their level of vulnerability or accessibility to needed social determinants of health interventions including but not limited to: food, housing, medication, child care, legal help, domestic violence services, employment, smoking cessation, sobriety services, and education.
New York City Online Pharmacy Plans To Expand Operations across US
The Wall Street Journal (8/8) reports that Capsule Corp., an online pharmacy, is preparing to expand its operations across the US. The company currently offers same-day delivery of prescription drugs in New York City, but plans to expand nationally over the next 18 months.
Hospital-At-Home Care: Potential to Improve Outcomes in Low-Risk Patients
Hospital-at-home (HaH) care offers acute hospital-level care for selected patients at home. In 2014, a New York healthcare system implemented a HaH care bundle with a 30-day postacute care period of home-based transitional care. Patients were admitted to HaH on weekdays from 8 a.m. to 4 p.m. only. HaH care was provided by a daily nurse visit and a daily assessment by a physician or nurse practitioner (in person or by video call). Services included vital sign measurements, administration of intravenous and oral medications, wound care, and patient education. For 30 days after discharge, nurses and social workers provided self-management support and coordination of outpatient care.
Compared with 212 control patients, 295 HaH patients had significantly shorter acute care length of stay (mean difference, 2.5 days); significantly higher patient satisfaction; and significantly lower 30-day hospital readmissions (16% vs. 9%), emergency department revisits (12% vs. 6%), and skilled nursing facility admissions (10% vs. 2%) in adjusted analyses. Daniel D. Dressler, MD, MSc, SFHM, FACP reviewing Federman AD et al. JAMA Intern Med 2018 Aug.
Analysis of ADHD Drugs: Use Methylphenidate in Kids, Amphetamines in Adults
A meta-analysis of the drugs used to treat attention-deficit/hyperactivity disorder in the short term finds the best choices to be methylphenidate in children and adolescents, and amphetamines in adults, according to a Lancet Psychiatry report.
Researchers examined efficacy and tolerability data from published and unpublished double-blind, randomized, controlled trials. The 133 trials included some 14,000 children and 10,000 adults. Other drugs evaluated in the “network meta-analysis,” which allows indirect comparisons of drugs not directly tested head-to-head, included atomoxetine, bupropion, clonidine, guanfacine, and modafinil.
Overall, results favored using methylphenidate in children and adolescents, and amphetamines in adults as first-line, short-term (12 weeks or under) treatment.
Asked to comment, Dr. Barbara Geller of NEJM Journal Watch Psychiatry wrote: “The two most effective drugs (methylphenidate for children, amphetamine for adults) should be prescribed first because they have good safety records after decades on the market.”
Non-Alcohol Fatty Liver Disease Patients Should Still Avoid Alcohol
People who have non-alcoholic fatty liver disease “that wasn’t caused by heavy drinking may still need to avoid alcohol if they want to prevent their liver damage from getting worse,” according to a Korean study published in Hepatology. Researchers examined 58,927 young and middle-aged adults in Korea with the disease and “moderate drinkers were 29 percent more likely to have worse fibrosis” by the end of the eight-year study than those who abstained. Light drinkers “were also 6 percent more likely to have their fibrosis become more advanced than people who avoided alcohol altogether.”
Garfunkel Wild ASC Symposium on Nov 2; MSSNY Members Receive $65 Discount
November 2, 2018 is Garfunkel Wild’s 5th Annual NY Metro ASC Symposium at the Marriott Marquis (Manhattan). Please find the agenda for the day and additional information by clicking here.
MSSNY members will be entitled to a $65 discount.
Nine Reads for Doctors from American Assoc. of Medical Schools
These books, from renowned physicians and other great science writers, will remind you why you went into medicine in the first place.
Upper East Side Plastic Surgery Office Available for Rent Part Time
Orthopedist to Rent Space
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Chief of Medical Services
MINIMUM QUALIFICATIONS: Possession of a license and current registration to practice medicine in New York State, plus six years of experience in the practice of medicine, two years of which must be in an administrative or supervisory capacity. Appointee must be eligible for and maintain eligibility for full and unconditional participation in Medicaid and Medicare programs. Appropriate certification by an American Medical Specialty Board and one year of post certification experience in that specialty can be substituted for four years of general experience.
PREFERRED QUALIFICATIONS: Board certification in Geriatric Medicine and/or Certification as a Medical Director (AMDA), and experience in a long-term care facility.
RESPONSIBILITIES: Serve as Medical Director of a 242-bed skilled nursing facility for veterans and their dependents. Provide medical leadership and oversight ensuring the delivery of quality health care services while also ensuring compliance with clinical, statutory and regulatory standards.Send resume to: NYS Veterans Home, Attn: Human Resources, 4207 State Highway 220, Oxford, NY 13830
The New York State Veterans Home at Oxford is a 242-bed skilled nursing facility operated by the NYS Department of Health located in Chenango County. It is an Affirmative Action/Equal Opportunity Employer.
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