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While regulatory policy has attempted to accelerate patient access to breakthrough therapies, reimbursement policy has failed to keep up. There are several reasons why. First, the U. The current system is not optimized to pay for the incoming wave of curative therapies with high one-time upfront costs and benefits that accrue over a lifetime , which may limit access to innovative but expensive therapies. Only five patients received Yescarta in the four months after regulatory approval , with waiting lists documented due to reimbursement challenges.
For certain conditions with high mortality rates, the risks of delay could be material e. Similarly, new curative therapies for hepatitis C virus HCV , first approved in , have also faced coverage hurdles. Between and April , public and commercial insurers denied new HCV treatments for more than a third of patients. In Medicaid, 31 states limited medication access to patients with advanced liver fibrosis or cirrhosis, even though treatment at earlier stages of disease has been shown to result in higher efficacy , lower annual lifetime post-treatment costs , and more life-years gained.
Further, patients treated after developing cirrhosis require additional monitoring and treatment, and remain at risk of liver cancer even after being cured. This is in contrast to treatments for other chronic diseases which are taken daily for a lifetime, are not curative, and when generic may cost several hundred dollars a year. Second, long-term clinical data on novel therapies is typically limited when a therapy is first approved.
Payers may rightly be reluctant to pay for therapies with uncertain long-term results. Third, patients frequently change insurers , which many have argued reduces the incentive for individual payers to cover the cost of curative therapies, since patients may not stay with the same payer long enough for the payer to enjoy potential savings afforded by these treatments, or to assess their long-term efficacy.
This argument is balanced, however, by the fact that for severe chronic conditions, patients may be reluctant to switch health plans. Fourth, dealing with novel treatments in the major government health programs can be particularly challenging. For therapies that will be used in an inpatient setting, Medicare payment occurs within the framework of the diagnosis-related group DRG system, whereby an inpatient stay is categorized into a particular DRG that determines the payment by Medicare to the hospital.
In the case of a new technology there may be no existing DRG that adequately captures the costs inherent in using the new therapy. Additionally, the tools available to regulators, such as the ability to allow an add-on payment for a new technology, may take time to put into place and may result in payments that fall below the cost of treatment.
Another issue is that in the case of drugs that are self-administered by patients, private plans that participate in Medicare Part D are required to submit annual bids that are used to determine the enrollee premium for the particular plan in the next plan year.
Those bids are due on the first Monday in June for the plan year beginning January 1. That long lag makes it difficult for plans to accurately predict the claims that will be incurred, especially for innovations that may not even be approved at the time that bids must be submitted. In Medicaid, individual states pay substantial shares of the program cost. States must budget for Medicaid in their annual or biennial government budgeting process, trading off Medicaid dollars against other state budget items such as education and infrastructure.
The inherent lags in budgeting, in addition to the political backdrop, can result in a situation in which new, expensive medical technologies may not be reimbursed. Solving these challenges will require a number of changes to payment models that must address several issues, including financing high upfront costs of treatment, ensuring that insurers only pay for treatments that deliver sustained responses, and recognizing that insurer incentives may not align well with treatments that have high upfront costs but benefits that accrue largely to future insurers.
For example , outcomes-based contracts , which reimburse manufacturers for treatments only in instances where the treatment taken by a given patient successfully achieves a predetermined clinical endpoint, can reduce the risk that plans spend too much up front for therapies that turn out to be less effective than initially thought and allow for this risk to be shared between drug manufacturers and payers. Such contracts, wherein reimbursement depends on whether predetermined target outcomes are achieved within a preset time period , have been used more widely in Europe, such as with various oncology treatments in Italy.
However, implementation is expected to increase in the United States, particularly with the incoming wave of cell and gene therapy approvals. Another model designed to address large upfront costs involves payment in installments , spread over a predetermined time period.
Installment payments help to overcome the short-term budgetary risk for expensive curative therapies. Although the installment model may be attractive for any potentially curative treatments to help spread the costs over time, it can be especially useful for chronic diseases where there may be a large existing stock of patients who now suddenly have a potential cure. Outcomes-based contracts may also even be structured to spread payment over time and hence help address the challenge of large upfront costs for many rare disease treatments.
Additionally, payers can reimburse Luxturna in installments spread over several years. Bluebird Bio and GlaxoSmithKline also offer similar outcomes-based, installment payment plans for their gene therapies Zynteglo and Strimvelis , respectively, in Europe. Implementation of these alternative payment models is not without potential challenges. Outcomes-based models require payer and manufacturer agreement on definitions of product performance, payment amount and schedule.
Additionally, patient outcomes may not be readily measurable through insurance claims data, or patients may switch insurers before long-term outcomes can be assessed. They may also be further complicated by statutorily-mandated discounts such as Medicaid Best Price.
Thus, the cooperation of regulators may be necessary for alternative payment models to fully achieve their potential utility. For installment-based models, payers and manufacturers must both agree on the payment amount and number of installments , with an added challenge of providers being less open to payment in installments from smaller health plans , whose long-term financial solvency may be uncertain.
Moreover, there is a need to clarify what happens if a patient switches insurers before all installments are paid. Given multiple approaches to reimbursing curative therapies, solutions might include a blend of various models rather than a single one. Another model that has been proposed is risk-pooling for curative therapies , whereby public and private payers set aside a portion of healthcare budgets into a dedicated fund. This approach helps to combat the problem created by patient turnover across insurers, which leads insurers to be less inclined to make large investments in patients who may switch to another health plan.
Curative therapies would be reimbursed using this fund to which all payers contributed, alleviating concerns about insurer-switching after curative treatment has been covered by a single payer. For instance, for patients nearing Medicare eligibility, it would make sense for Medicare to potentially share in costs of treatment with other insurers, as has been proposed in HCV.
CareSource's percent growth was more than double the average revenue growth of the other 99 largest Dayton companies in that time frame. CareSource used this opportunity to create a plan which assimilates both Medicaid and Medicare into one CareSource health plan. CareSource celebrated 25 years as one of the nation's largest Managed Medicaid Plans and the largest in Ohio in The company then served more than 1 million consumers in Ohio and Kentucky.
In late and early a new division of CareSource was launched to address the other unmet needs of the company's Ohio Medicaid population.
Through a partnership with Fuyao Glass America , the company was able to set up interviews for 40 members for full-time employment with the manufacturing company. This new approach informed the way CareSource began to see its members. In , CareSource began serving members in West Virginia through its health exchange product and was awarded the contract to serve Medicaid populations in Indiana  and Georgia. The growth in membership was matched by growth in the number of employees.
A lease was signed for some employees to move into space on two floors of the Kettering Tower, which was renamed Stratacache Tower in ,  in downtown Dayton to make room for a total of 2, employees in the city.
The new building would provide space for employees and create a campus-like environment in the urban core. In CareSource became the largest locally owned company by revenue in the Dayton-area after Marathon Petroleum Corp. The CareSource Foundation celebrated its 15th Anniversary in Headquartered in Dayton, Ohio, CareSource has a workforce of 4, employees and covers nearly 2 million members.
There are satellite offices in the Ohio cities of Cleveland and Columbus , as well as Atlanta , Indianapolis , and Louisville, Kentucky. From Wikipedia, the free encyclopedia. Health Insurance Provider. Dayton, Ohio. United States. Ernst and Young. Dayton Business Journal. Cincinnati Business Courier. Retrieved Columbus Business First.
Archived from the original on November 20, Archived from the original PDF on Archived from the original on Dayton Daily News. Modern Healthcare. Dayton Local. CEO Today. Ohio Department of Medicaid.
Wade was overturned by the Supreme Court. Malone-King says she knows other women who have received the same news about their treatment. There is nothing life-affirming about that at all. At least one state ï¿½ Texas ï¿½ allows pharmacists to refuse to fill prescriptions for misoprostol and methotrexate, which together can be used for medical abortions.
Chronic illness advocates are stupefied. Nitika Chopra, the founder of Chronicon , an online and in-person community for people dealing with chronic illness, says that she has been flooded with messages from women who are terrified.
She herself was on methotrexate when she was experiencing severe psoriasis and psoriatic arthritis. At the height of her illness a few years ago, was unable to walk without it. Chopra is now on a different course of medication but the thought of chronically ill women being denied the treatment they need infuriates her.
Instead, the politicians who have been elected to serve women are now endangering them. Anti-abortion advocates often gratuitously exploit public sympathy for disabled children to push deadly policies. Women with disabilities and chronic illnesses are not in incubators. Taken to its extreme, the anti-abortion movement is a threat to everyone. IE 11 is not supported. Because it is a chronic illness that requires proper management and treatment, when access is denied, it can have devastating consequences.
Having to deal with diabetes is challenging enough, but adding in there the navigation of the insurance process to get your life saving treatments supplied is truly a nightmare. In terms of insurance denials there are many different variables that need to be considered in determining your plan and what supplies are covered. If you are not denied and supplies are not received: this could be for a couple reasons:.
Here are the steps to take when you are denied coverage by your insurance company for a treatment option whether medical supplies or diabetes devices that your doctor determines to be medically necessary for you.
Ask your doctor to take a look over your records then resubmit your claim on your behalf. Find out if your doctor can write you a letter of medical necessity for the supplies or device.
This is important to try to get done ASAP as it will help to strengthen your argument for coverage. This process is when your doctor talks with another medical professional typically one from the insurance company to explain why these items are medically necessary for you. After their conversation is completed, you should know within a day if you are approved by your insurance.
Many insurance companies hope that you will give up during this time because of the wait, but DO NOT give up. Here are some tips on how to write your appeal:. After a month to two months you will either be approved or get denied again. Young children with Type 1 diabetes are getting denied life-saving supplies and devices at an alarming rate from insurance companies.
Typically, the reasons for these denials are that the requested supplies or devices are only for convenient purposes more so than for therapeutic purposes. The problem many parents and medical professionals of young children with diabetes are having are that these supplies and devices could help to enhance the treatment of young children as well as ease the worries and fears of parents battling this disease right alongside of their children.
Medicaid and Medicare have been two of the state issued insurance plans that have continued to deny CGMs one after the other. Thankfully, as of January 12, this may begin to change. You can read more about this monumental ruling here.
But the jist of what is happening is Medicare will now cover therapeutic CGMs. To be considered a therapeutic CGM you must be able to make dosing decisions based on the data you see on the device without having to test your blood glucose levels with a blood glucose meter. With this ruling CGM systems are still only going to be approved right now on a case by case, that means even though they are considered to be a durable medical equipment, parents and medical professionals may still have a difficult time getting children the coverage they need.
With that being said, if you find that your child has been denied something that their doctor deemed medically necessary, there are certain steps you can follow to try to get it covered under your health insurance.
Most insurance plans, private, state, etc. This has to be completed before you make any written appeals. Your doctor will have a conversation on the phone with a medical doctor in the insurance company. They will discuss why the item was denied and why it is beneficial. Many states mandate that there is some sort of insulin pump coverage. However, they do not state that it has to be one of your choosing. You may need to follow through with an appeal if the specific pump you wanted for your child is denied.
They may require you choose a different model that is lower in costs. This process can be won, but it may take some time and many appeals to succeed.
So to see the most benefits from it you would want to have both of these devices in use first.
WebCareSource covers all medically necessary Medicaid-covered drugs at many pharmacies. CareSource also covers many commonly used over-the-counter (OTC) medications . WebDon't have an account? Sign up. WebJan 14, ï¿½ï¿½ CareSource verifies that there are no outstanding fraud, waste and abuse issues as well as no internal quality concerns. For Pharmacy Selection - Note: Due to State Law and Medicaid requirements, members must have a referral from their healthcare provider (physician, nurse practitioner, or physician assistant) before a pharmacist may .