Navvis Right Now: Issue 14 – March 9, 2019

March 14, 2019

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FDA Approves Controversial Drug for Depression

The Food and Drug Administration approved J&J’s controversial drug for depression Tuesday that is groundbreaking but also raises concerns about abuse. The drug, Spravato, is a close chemical relation to ketamine, an anesthetic that is known for its heady effects on the brain. It is often abused as a party drug with the nickname “Special K,” but it has also been shown in studies to have a fast-acting impact on depression symptoms. The discovery that ketamine can help ease symptoms of depression—and within hours, rather than the weeks required for antidepressants such as Prozac or Zoloft—has shaken up the field of psychiatry. The FDA also said it must be administered in a certified medical office where the health-care provider can monitor the patient.  Spravato will cost between $590 and $885 per treatment session, depending on the dose. For the standard regimen, that will amount to $4,720 to $6,785 for the first month, and about $2,360 to $3,540 a month thereafter. (For the clinical description, see the attached WSJ article, which depicts how Esketamine restores nerve cell, or synaptic, connections.)

Takeaway:  This is significant because no new class of drugs has come on the market for depression in decades. As regularly discussed, depression is a serious health condition and is one of the most common mental disorders in the U.S. The NIMH estimates that 16.2 million or 6.7% of all U.S. adults have at least one major depressive episode. J&J estimates about three million to five million Americans suffer from treatment-resistant depression, which is why Spravato was developed.

Technology Could Transform Care for People on Medicaid

For diabetes patients who want reminders about when to take their insulin, or young mothers looking for tips on nursing, new digital technologies — from apps and text-messaging services to remote monitoring tools and wearable sensors — are making life easier and even leading to better outcomes. The Commonwealth Fund reported one nonprofit, CareMessage, has found that when a free clinic sent patients with diabetes two daily questions and two weekly educational messages over 12 weeks, the patients had lower blood glucose levels than they did before the texts. There has been a misperception among health care entrepreneurs that low-income people may not have cellphones or smartphones with which to access digital tools. In fact, 92 percent of adults earning less than $30,000 have cell phones, and 67 percent have smartphones. Another reason tech companies have been wary is that Medicaid pays providers lower reimbursement rates than commercial health plans or Medicare. For example, developing tools to support pregnant mothers and healthy deliveries would disproportionately impact Medicaid spending because Medicaid pays for 50 percent or more of all births in 24 of 50 states.

Takeaway:  As Medicaid expands and there is a continued focus at both the Federal and State level on how to pay for Medicaid, states are looking for solutions that can help rein in costs and technology innovation can provide an answer. HealthTech4Medicaid (HT4M) is a new advocacy group that was founded in November by more than 40 healthtech CEOs with a $1B with a vision to further improve quality and access to care for Medicaid recipients.  HT4M is focused on radically change the pace of innovation in Medicaid with educational programming, resources and tools to facilitate cutting-edge partnerships for venture-backed entrepreneurs, payers and providers. They have an impressive leadership Council as well which is comprised of 16 experienced healthcare experts, including Dignity Health, Leavitt Partners, BlueShield and Mark McClellan.

Every Senior Needs Cognitive Screening

In its annual report, the Alzheimer’s Association includes a call for action to the nation’s primary care physiciansEvery senior should receive a brief cognitive assessment at their first Medicare annual wellness visit at age 65, the association says, and the exams should be a regular part of their ongoing annual care. Yet a survey by the association found that early cognitive assessments were not the norm during most senior doctor visits. “The survey found a really troubling underuse of cognitive assessments during the annual healthcare checkup,” said Pike who leads the Association. “Despite a strong belief among seniors and physicians that cognitive assessments are important for the early detection of Alzheimer’s, only half of the seniors in the survey were being assessed for cognitive decline. And only 16% [of] seniors received regular follow-up assessments.” A comparison of those statistics against those of other wellness checkup items give a clear picture of the disparity, Pike said. In each visit, physicians check cholesterol 83% of the time, vaccinations 80% and blood pressure 91% of the time, she said. “So while physicians say it’s important to assess all patients age 65 or older, fewer than half are saying that it’s part of their standard protocol,” she said.

Takeaway: Signs of memory loss or confusion associated with Alzheimers and dementia are subtle when they first appear. Removing the stigma and encouraging people to discuss memory loss concerns and confusion with their health care providers and families can help detect and diagnose problems earlier when more can be done to slow the progression. The article also highlighted not only the need to increase the confidence and the skills of front-line providers so they can provide more care in this area, but also how patients can use the additional time to get their affairs in order while they can. This act reduces stress that can improve the patient’s quality of life and ease family burdens before the disease progresses.

Azar: Kidney Dialysis Needs to Move to Patient Homes 

HHSSecretary Alex Azar outlined on Monday a value-based plan for transforming kidney care that emphasizes at-home treatment and contains new incentives for transplantation. Kidney disease accounted for more than one-fifth of all Medicare spending in 2016, or about $113 billion. The program covers people under 65 who suffer from end-stage renal disease that can only be treated with dialysis or a transplant. “Today, 88% of Americans with end-stage renal disease start treatment with center-based dialysis. Just 12% start treatment at home with hemodialysis or peritoneal dialysis” said Azar. This is the complete opposite of the situation in some of our peer nations, including Hong Kong, where more than 80% of patients benefit from some form of in-home dialysis. Home-based dialysis is more convenient, better for patients’ independence and self-sufficiency and better for their physical health. Azar also announced HHS is trying to boost the number of organs available for transplant across the country by identifying more organs safe for transplant, bringing more living donors into the system and spurring development of implantable artificial kidneys. Dialysis giant Fresenius Medical Care just received FTC approval for the company’s $2 billion merger with NxStage Medical., a hemodialysis machine manufacturer. (The FTC dissenters were concerned the merger “could thwart other competitors from entering the home hemodialysis market,” according to a report by Healio.)

Takeaway:  This is a positive step for patients, their families and CMS who spends $1 out of every $5 on dialysis patients. There are three different forms of home hemodialysis including conventional, short daily hemodialysis and nocturnal home dialysis where the patient receives the treatment while they sleep. Home dialysis is less expensive, more convenient and oftentimes safer, but it does require someone else to assist with the treatments. Medicare launched ESRD Seamless Care Organizations, or ESCO ACOs, a few years ago and they are saving Medicare about $2,000 per patient per year and reducing hospitalizations.  For patients receiving dialysis at a center, they have to arrange transportation and typically require treatment 3 times a week with 3-4-hour sessions and many of these patients still work.

At the Tip of the Spear of Payment Reform: Can Complex Care Management Be Made Workable? 

An article was published in the NEJM Catalyst focusing on improving patient care and driving value at health care organizations. A number of core elements of care management for patients with complex medical needs will have to be modified—some of them including federal policy and payment elements—in order for the U.S. healthcare delivery system to succeed in that important area. “Effective management of high-need, high-cost individuals is integral to the success and sustainability of a value-driven health care system,” Patients make up 5 percent of the population but account for more than 50 percent of U.S. health care spend. Complex care management programs coordinate essential services, address critical gaps in communication, and prevent costly, avoidable hospitalizations and other urgent care services and are moving into nonmedical SDoH. The authors summarize that the core problem is payers are supportive of care management services but may not adequately pay for those services outside of their own programs. This fundamental disconnect creates a piecemeal system in which programs are not scalable across lines of business, do not provide secure funding streams and may compel providers to ration care.  Interestingly enough, yesterday BCBS North Carolina announced launching a “Primary Care Initiative for High Quality, Coordinated Patient Care” focusing on intensive primary care. BCBSNC has entered into agreements with multiple national leaders including Iora Primary Care, CityBlock Health, and CareMore Health. “Intensive primary care is better care. When patients with multiple health issues have access to intensive primary care, we know they’re more satisfied, and we know it improves their overall quality of care and reduces total cost of care,” said Rahul Rajkumar, MD, chief medical officer of Blue Cross NC. Intensive primary care provides a high focus on improving the patient experience and the quality of care. These practices will feature team-based care, a dramatically lower number of patients for each physician, and care that addresses the social determinants of health. They will operate under value-based arrangements that change the payment structure and demand better outcomes.

Takeaway: BCBSNC’s new announcement supports the authors need for payment reform. For BCBSNC, The Primary Care Initiative is a value-based arrangements, insurers pay providers up-front fixed fees to offer a wide range of valuable services to patients. In turn, the providers are held financially accountable for patient outcomes and total health care costs.  This is one more step for BCBSNC in achieving their goal of having all customers covered under value-based care contracts within five years. By early 2020, fifty percent or more of all Blue Cross NC members will have a provider who is jointly responsible for the quality and total cost of their care.


Disclaimer: This blog includes content gathered from other published sources, not authored by Navvis, and is presented as information only. As with any news story, this information may have changed since its publication date. Commentary included with the information is the opinion of its authors, and is not indented to provide legal or regulatory advice or guidance to the reader. Navvis does not represent the accuracy of or assume liability for the content presented herein.