DRG Market Access Week In Review

NCQA Releases Annual Review of US Health Plans

The National Committee for Quality Assurance (NCQA), on September 21, released its 2016–2017 ratings, evaluating 1,012 health plans across the nation. This year, 23 plans received a rating of 5 out of 5. Among them were: 13 commercial plans, including such familiar names as Blue Cross Blue Shield, Kaiser Foundation, Tufts, University of Pittsburgh Medical Center, and Johns Hopkins; 8 Medicare plans, 5 of which were Kaiser Foundation plans; and 2 Medicaid plans (Jai Medical Systems Managed Care Organization and Kaiser Foundation Health Plan Inc–Hawaii). NCQA evaluates plans on 3 metrics: consumer satisfaction, based on patient surveys; prevention, which examines how well plans provide preventive services such as screenings and immunizations; and treatment, which studies outcomes for chronic and acute conditions. States with the highest percentage of plans receiving a 4.5 or 5 include Massachusetts, Rhode Island, Wisconsin, Maine, New Hampshire, Minnesota, Vermont, and New York. Overall, well-performing plans were more prevalent than poor performers, NCQA reported. Ten percent of plans received a rating of 4.5 or 5, while only 3% earned a rating of 1–2. According to the NCQA, high-quality options are available across plan types: The percentage of top-rated plans was relatively consistent among commercial, Medicare, and Medicaid plans.

Medicaid Enrollment Slows After Years of Dramatic Growth

This was the finding of a new PwC report, “The Steadying State of Medicaid in the United States.” In 2016, Medicaid grew by only 3%, to a total of 75.2 million Americans. However, overall growth since 2013 is 31%, due to the expansion of Medicaid eligibility under the Affordable Care Act. Currently, nearly a quarter of the US population is covered under Medicaid—and 73% of those are in managed Medicaid plans. Indeed, since 2013, private Medicaid plans have added more than 20 million enrollees, while public programs have seen enrollment drop by nearly 3 million. The study also cites the “Medicaid Expansion Gap”—the number of individuals who would be added to the Medicaid roster if all states adopted Medicaid expansion (32 states have, including the District of Columbia). For 2016, this number is approximately 5 million, meaning the most dramatic expansion-related growth enrollment has already occurred.

Controversy Swirls Around New Duchenne Muscular Dystrophy Drug



On September 19, the Food and Drug Administration (FDA) approved Sarepta Therapeutics’ new Exondys 51, the first drug to treat Duchenne muscular dystrophy (DMD), a rare but deadly condition. However, in doing so, the agency overruled the recommendations of its own medical staff, who said the study on which the approval was based was “misleading” and called for its retraction. At the heart of the controversy is the small subpopulation for whom the drug is indicated—young boys with DMD who exhibit a certain genetic mutation causing progressive muscle degeneration. The condition typically leaves patients unable to walk by their teen years and can be fatal, often at around age 25, due to weakening of the heart and pulmonary muscles. Without other options, patients and their families lobbied the FDA for approval, and were deemed instrumental in the drug’s passage. Approval of the drug—expected to cost approximately $300,000 per year—was based on preliminary data from only 12 patients, showing that Exondys 51 could strengthen muscles. The data did not, however, reveal whether the drug would improve symptoms. Regarding that initial study, FDA acting chief scientist Luciana Borio, MD, noted, “I would be remiss if I did not note that the sponsor has exhibited serious irresponsibility by playing a role in publishing and promoting selective data during the development of this product.” Still, the FDA requires Sarepta must conduct a larger clinical study examining whether the drug can improve function for patients. If the study fails to produce positive results, approval could be withdrawn.

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