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This Week in Health Care Reform: April 6th, 2018

CMS finalizes proposed changes to Medicare Advantage; lawmakers launch a probe into the latest cancer drug price increase; and, stakeholders leverage the power of data in the fight to address opioid misuse.

Week in Review

Medicare Advantage: As expected, the Centers for Medicare & Medicaid Services (CMS) on Monday released its finalized policy and payment updates to the popular Medicare Advantage program.  Stakeholders commended the agency for its commitment to shoring up the program and demonstrating an abiding willingness to work with them to ensure that beneficiaries are able to continue to access the innovations and comprehensive, coordinated care that sets Medicare Advantage apart from traditional fee-for-service Medicare.  While experts continue to analyze the extent to which CMS’ finalized changes will impact health plans, the impact to beneficiaries is already clear, owing to the expansion of how CMS will define “primarily health-related” benefits going forward.

Cancer Drug Probe: A more than 40-year old drug used to treat brain tumors and Hodgkin lymphoma finds itself at the roiling center of a growing maelstrom as a result of its price having gone up 1400 percent since 2013.  That drug, lomustine, cost $50 back then – today, that same dose costs $768.  In fact, since the drug – which has no generic competition – was initially acquired by NextSource Biopharmaceuticals, a subsidiary of Tri-Source Pharma, its price has gone up nine times.  As a result, a trio of Senators – Susan Collins (R-Maine), Catherine Cortez-Masto (D-Nevada), and Claire McCaskill (D-Missouri) – sent a letter last month to Tri-Source’s CEO demanding an explanation.

Opioid Data:
As the opioid epidemic continues to ravage communities all over the country, stakeholders across the health care spectrum have trained their collective sights on combatting the issue.  While the means may not have always been the same, the overarching ends generally have been.  Now, a shared focus on population health – specifically, social determinants of health (SDoH) – has helped stakeholders find greater alignment in regards to the former, as well.  Recognizing the roles that economic and social upheaval play in the misuse of opioids, health systems have begun to leverage the vast amounts of data that they collect in order to catch people before they fall into opioid addiction.  These stakeholders, including payers, providers, and community groups, share data on SDoH factors, e.g., poverty rates or access to transportation, as a way of spotting potential at-risk populations.  Buoyed by research that shows how opioid addiction operates synergistically with SDoH, there’s growing acknowledgment and recognition that the issue is often fueled by structural factors, such as lack of economic opportunity and eroded social capital.  In fact, experts point out, the prevalence of these factors in depressed communities often serves as one of the root causes of opioid addiction.      

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Last week, California’s Attorney General announced that his office had filed a lawsuit against Sutter Health, the largest health system in the northern part of the state.  The lawsuit follows a statewide investigation into health care prices that revealed significant price disparities across California.  Specifically, the AG’s office claims that the organization’s anticompetitive practices are responsible for driving up prices across the region.  The lawsuit also alleges that Sutter’s actions fueled acquisitions that resulted in further consolidation and funding for its own health plan.

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