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Journal: Journal of managed care & specialty pharmacy


Payment for health care services, including oncology services, is shifting from volume-based fee-for-service to value-based accountable care. The objective of accountable care is to support providers with flexibility and resources to reform care delivery, accompanied by accountability for maintaining or improving outcomes while lowering costs. These changes depend on health care payers, systems, physicians, and patients having meaningful measures to assess care delivery and outcomes and to balance financial incentives for lowering costs while providing greater value. Gaps in accountable care measure sets may cause missed signals of problems in care and missed opportunities for improvement. Measures to balance financial incentives may be particularly important for oncology, where high cost and increasingly targeted diagnostics and therapeutics intersect with the highly complex and heterogeneous needs and preferences of cancer patients. Moreover, the concept of value in cancer care, defined as the measure of outcomes achieved per costs incurred, is rarely incorporated into performance measurement. This article analyzes gaps in oncology measures in accountable care, discusses challenging measurement issues, and offers strategies for improving oncology measurement. Discern Health analyzed gaps in accountable care measure sets for 10 cancer conditions that were selected based on incidence and prevalence; impact on cost and mortality; a diverse range of high-cost diagnostic procedures and treatment modalities (e.g., genomic tumor testing, molecularly targeted therapies, and stereotactic radiotherapy); and disparities or performance gaps in patient care. We identified gaps by comparing accountable care set measures with high-priority measurement opportunities derived from practice guidelines developed by the National Comprehensive Cancer Network and other oncology specialty societies. We found significant gaps in accountable care measure sets across all 10 conditions. For each gap, we searched for available measures not already being used in programs. Where existing measures did not cover gaps, we recommended refinements to existing measures or proposed measures for development. We shared the results of the measure gap analysis with a roundtable of national experts in cancer care and oncology measurement. During a web meeting and an in-person meeting, the roundtable reviewed the gap analysis and identified priority opportunities for improving measurement. The group determined that overreliance on condition-specific process measures is problematic because of rapidly changing evidence and increasing personalization of cancer care. The group’s primary recommendation for enhancing measure sets was to prioritize and develop effective cross-cutting measures that assess clinical and patient-reported outcomes, including shared decision making, care planning, and symptom control. The group also prioritized certain safety and structural measures to complement condition-specific process measures. Further, the group explored strategies for using clinical pathways and devising layered measurement approaches to improve measurement for accountable care. This article presents the roundtable’s conclusions and recommendations for next steps.

Concepts: Health care, Medicine, Health insurance, Cancer, Oncology, Chemotherapy, Tumor, Cancer patient


Taking medications as prescribed is imperative for their effectiveness. In populations such as Medicare, where two thirds of Medicare beneficiaries have at least 2 or more chronic conditions requiring treatment with medications and account for more than 90% of Medicare health care spend, examining ways to improve medication adherence in patients with comorbidities is warranted.

Concepts: Health care, Pharmacology, Medicine, Health insurance, Pharmaceutical drug, Pharmacy, Health science, Diagnosis-related group


Patients receiving psychiatric services at community mental health centers (CMHCs) are often prescribed medication that is critical to the treatment of behavioral health conditions, including schizophrenia, bipolar disorder, anxiety, and depression. Previous studies have shown correlation between rates of medication adherence and risk of hospitalization, but potential differences in medication adherence and other outcomes for patients of CMHCs by pharmacy type have not been widely studied.

Concepts: Psychology, Hospital, Mental disorder, Schizophrenia, Psychosis, Bipolar disorder, Pharmacy, Suicide


Tiered formularies, in which patients pay copays or coinsurance out-of-pocket (OOP), are used to manage costs and encourage more efficient health care resource use. Formulary tiers are typically based on the cost of treatment rather than the medical appropriateness for the patient. Cost sharing may have unintended consequences on treatment adherence and health outcomes. Use of higher-cost, higher-tier medications can be due to a variety of factors, including unsuccessful treatment because of lack of efficacy or side effects, patient clinical or genetic characteristics, patient preferences to avoid potential side effects, or patient preferences based on the route of administration. For example, patients with rheumatoid arthritis may be required to fail low-cost generic treatments before obtaining coverage for a higher-tier tumor necrosis factor alpha inhibitor for which they would have a larger financial burden. Little is known about stakeholders' views on the acceptability of greater patient cost sharing if the individual patient characteristics lead to the higher-cost treatments.

Concepts: Health care provider, Pharmacology, Medicine, Patient, Illness, Ethics, Cost, Tumor necrosis factor-alpha


Recently published asthma guidelines by the European Respiratory Society and the American Thoracic Society (ERS-ATS) define severe disease based on medication use and control level. These guidelines also emphasize that asthma severity involves certain biomarker phenotypes, one of them being eosinophilic phenotype. The quantification of the influence of eosinophil level toward predicting disease severity can help decision makers manage therapy better earlier.

Concepts: Scientific method, Medicine, Decision making, Asthma, Phenotype, Uncertainty, Control, The Europeans


The European Respiratory Society and American Thoracic Society (ERS/ATS) published guidelines in 2014 for the evaluation and treatment of asthma. These guidelines draw attention to management of patients with asthma that remains uncontrolled despite therapy. One phenotypic characteristic of therapy-resistant asthma is eosinophil elevation. It is important to better understand the burden of care gaps in this patient subgroup in order to support improved treatment strategies in the future.

Concepts: Immune system, White blood cell, Asthma, Patient, Future, The Europeans, Eosinophil granulocyte


Medication nonadherence is problematic throughout health care practice. Patient nonadherence is a result of several factors, such as financial issues, confusion about the medication, or concerns about possible side effects. Efforts to improve adherence have been implemented, but new strategies are needed to ensure that patients fill their medication prescriptions and adhere to their prescribed use.

Concepts: Health care, Health care provider, Medicine, Health, Patient, Illness


The Biologics Price Competition and Innovation Act, introduced as part of the Affordable Care Act, directed the FDA to create an approval pathway for biologic products shown to be biosimilar or interchangeable with an FDA-approved innovator drug. These biosimilars will not be chemically identical to the reference agent. Investigational studies conducted with biosimilar agents will likely provide limited real-world evidence of their effectiveness and safety. How do we best monitor effectiveness and safety of biosimilar products once approved by the FDA and used more extensively by patients?  OBJECTIVE: To determine the feasibility of developing a distributed research network that will use health insurance plan and health delivery system data to detect biosimilar safety and effectiveness signals early and be able to answer important managed care pharmacy questions from both the government and managed care organizations. METHODS: Twenty-one members of the AMCP Task Force on Biosimilar Collective Intelligence Systems met November 12, 2013, to discuss issues involved in designing this consortium and to explore next steps. RESULTS: The task force concluded that a managed care biosimilars research consortium would be of significant value. Task force members agreed that it is best to use a distributed research network structurally similar to existing DARTNet, HMO Research Network, and Mini-Sentinel consortia. However, for some surveillance projects that it undertakes, the task force recognizes it may need supplemental data from managed care and other sources (i.e., a “hybrid” structure model). CONCLUSIONS: The task force believes that AMCP is well positioned to lead the biosimilar-monitoring effort and that the next step to developing a biosimilar-innovator collective intelligence system is to convene an advisory council to address organizational governance.

Concepts: Health care, Health insurance, Pharmacy, Innovation, Patient Protection and Affordable Care Act, Consortium, Systems intelligence, Consortia


In 2012 U.S. diabetes costs were estimated to be $245 billion, with $176 billion related to direct diabetes treatment and associated complications. Although a few studies have reported positive glycemic and economic benefits for diabetes patients treated under primary care physician (PCP)-pharmacist collaborative practice models, no studies have evaluated the cost-effectiveness of an endocrinologist-pharmacist collaborative practice model treating complex diabetes patients versus usual PCP care for similar patients.

Concepts: Hospital, Costs, Diabetes, Physician, Economics, Model, Cost, Pediatrics


Current federal laws and FDA regulations have significantly restricted the sharing of clinical and health economic information on biopharmaceuticals that have yet to receive FDA approval. Over the past several years, organizations that make health care coverage decisions, including those that set copayments, premiums, and formulary placement, have expressed a need for receiving this information before approval, as long as appropriate safeguards exist to prevent this information from reaching unintended entities. Population health decision makers have indicated that waiting until FDA approval is often too late for the critical planning, budgeting, and forecasting associated with health benefit design, especially given the recent influx of high-cost medications and scrutiny for better evaluation and preparation. Recognizing that securities laws restrict the disclosure of nonpublic information and may need to be amended, permissible early dissemination would allow population health decision makers to incorporate clinical and economic information for pipeline drugs or expanded indications into financial forecasting for the following year’s plan. Access to this information is needed 12-18 months before FDA approval when organizations are deciding on terms of coverage and budgetary assumptions for state health insurance rate filings, Medicare and Medicaid bids, contracts with health care purchasers, and other financial arrangements. The need for exchange of clinical economic information before FDA approval was first introduced at a previous Academy of Managed Care (AMCP) forum in March 2016, which addressed section 114 of the Food and Drug Administration Modernization Act and the communication of such information after FDA approval. To address preapproval information specifically, AMCP convened a Partnership Forum on September 13-14, 2016. This forum included a diverse group of stakeholders representing managed care, the biopharmaceutical industry, providers, patients, health economists, academia, and others. The multistakeholder group represented the key professionals and entities affected by the federal laws and FDA regulations that restrict the sharing of preapproval information and the collective credibility necessary for proposing this new communication process. Forum participants primarily focused on 6 items of discussion: (1) creating and defining new terms for how biopharmaceutical manufacturers may provide clinical and economic information 12-18 months before FDA approval; (2) defining the clinical and scientific standards that this information should meet; (3) determining which entities should have access to this information and the value to each; (4) the format and process by which this information should be disseminated; (5) developing definitions for existing terms referenced in current laws, regulations, or guidance documents that would need to be modernized to align with the identified new term; and (6) providing safeguards to prevent this information from reaching unintended entities. Forum participants selected “preapproval information exchange” (PIE) as the correct term to describe this proposed new communication process and to be inclusive of data from pivotal phase III clinical trials, pharmaco-economic data, and patient-reported outcomes, as well as other relevant items, including anticipated indications, place in therapy, and routes of administration. Stakeholders agreed that PIE should be truthful, non-misleading, and include a broad range of information to meet the needs of population health decision makers and health care technology evolution. Recipients of PIE would be limited to population health decision makers who need this information for coverage decisions. The format and process for PIE disseminated should allow for a bidirectional exchange between manufacturers and population health decision makers but should not be proscribed in legislation. Furthermore, new legislative language may be beneficial, since PIE is a novel category of information. New legislation could provide a safe harbor and clarity that PIE does not violate preapproval promotion and the Federal Food, Drug, and Cosmetic Act and its regulations.

Concepts: Health care, Health economics, Medicine, Health insurance, Clinical trial, Communication, Food and Drug Administration, Biopharmaceutical