Years before the oldest baby boomers reached retirement age, the healthcare industry began to prepare for the impact of an aging generation. Healthcare providers and organizations have dedicated time and resources to studying the needs of boomers and adapting to meet them. Now, as approximately 10,000 baby boomers per day turn 65, the healthcare industry faces the challenge of continuing to deliver targeted care to boomers while simultaneously adopting new practices to meet the care expectations of the largest living adult population in the United States: millennials.

An Intrado survey that compared the healthcare expectations of baby boomers and millennials found that both patient demographics desire more and better communication from their healthcare teams. However, boomers and millennials have their own unique needs and communication preferences, so it is important to have patient engagement strategies in place for each of these distinct patient groups. Healthcare teams that do may be able to increase patient satisfaction and elevate the quality of care for both baby boomers and millennials.

How to Engage Different Generations with Their Healthcare Benefits

According to Intrado’s survey of 1,036 U.S. adults, nearly two in three baby boomers (64%) say they wish healthcare providers would communicate more often between appointments. Given that older Americans typically have greater healthcare needs, this interest in communication isn’t particularly surprising.

What is surprising is the fact that even more millennials than boomers say they want to engage with their doctors between appointments. More than three in four millennials (76%) wish for more frequent communication from healthcare providers between visits-proving that both age groups of patients want their providers’ attention.

Fortunately, giving them that attention may be simpler than it seems.

Tips for communicating with boomers and millennials

Many healthcare teams already have and use patient engagement technology to send patients messages to remind them about upcoming appointments. By leveraging the same technology that is used to send appointment reminders, healthcare providers can deliver personalized text, phone, and email messages that give baby boomers and millennials more of the meaningful between-visit communication they crave. The following examples show a few of the opportunities healthcare teams have to engage boomers and millennials through routine communication:

Email baby boomers information about managing chronic disease

 of adults age 65 or older have a chronic condition, and 68% have two or more. Sending patients emails to share valuable disease-specific information is a simple and effective way to support baby boomers with at-home chronic disease management. By the year 2030, an estimated one in four 

baby boomers will have diabetes, and one in three will be obese

. Healthcare teams can offer support by sending a series of emails about nutrition, for example, to boomer patients. Baby boomers suggest this type of communication is welcome. According to Intrado’s survey, more than one in three baby boomers (34%) currently feel that healthcare providers do not effectively communicate recommendations that are specific to their individual needs. So, baby boomers would likely welcome disease-specific communications from their healthcare providers.

Text millennials to invite them to schedule preventive exams

Scheduling wellness exams and preventive procedures is not always a priority for younger adults-particularly if they do not have any known health issues. For busy millennials, it is easy to deprioritize preventive healthcare behind family, work, and play. Because many millennials are not aware when they are due for preventive care, it can be helpful for healthcare teams to send them alerts when they are due for preventive screenings or exams. Text alerts work well for this because they are convenient for patients, and because millennials are adept at texting. Intrado’s survey revealed that 94% of millennials want to receive text, voice calls, or email prompts to schedule appointments or take other similar actions.

Send baby boomers messages to support medication adherence

 Older Americans often have more prescriptions to keep track of than younger adults. Intrado’s survey revealed that 88% of baby boomers feel that to create ideal healthcare experiences, it is important for healthcare teams to send them reminders when their medications are available to be picked up or when prescriptions need to be refilled. Healthcare teams can easily send automated messages that remind patients to pick up prescriptions, clarify dosage instructions, provide instructions on what to do if side effects become troublesome, or request that patients contact them if they are unable to afford their medications.

Create a wellness newsletter to send to millennials

According to Intrado’s survey, 97% of millennials say they want healthcare providers to support them in managing their health between office visits. If patients are already healthy-and even if they are not-sharing wellness tips and information is a good way to encourage patients to adopt healthy behaviors or make lifestyle improvements. Sending a quarterly newsletter that covers topics such as smoking cessation and weight management, for example, is an easy way to communicate wellness advice to patients and encourage them to take steps to improve their health.

Send baby boomers messages to help clarify financial responsibilities

 The cost of healthcare is a concern for patients of every age; however, because many baby boomers live on a low or modest income, they may be particularly wary of high-cost healthcare. Following retirement, boomers sometimes have a lot of questions about transitioning from private health insurance to Medicare. To answer questions and help patients overcome financial barriers, healthcare teams can send baby boomers automated messages to share Medicare resources or highlight healthcare services that patients can receive for little or no out-of-pocket cost.

Despite the multitude of opportunities for healthcare teams to communicate with patients, regular between-visit communication is typically uncommon. As a result, fewer than half of baby boomers (45%) and only 66% of millennials surveyed by Intrado said they believe their healthcare providers want to communicate with them between appointments. Fortunately, healthcare teams can easily demonstrate their commitment to supporting patients-from millennials to baby boomers-by using their patient engagement technology to improve and increase communication.

These examples illustrate a small handful of ways healthcare teams can use tailored automated communications to address the needs of both baby boomers and millennials and offer value between in-person appointments.    

Nate Brogan currently serves as president of Notification Services at 

, where the healthcare mission is to help organizations harness communications to expand the boundaries of where, when, and how healthcare is delivered.

Articles

Millennials and Baby Boomers aren't so different after all. 

Baby Boomers and Millennials Want More Frequent Communication

Although investing in housing construction and rehabilitation is relatively new for most hospitals and health systems, a new guide argues that hospitals’ institutional assets, focus on health outcomes, and position as anchor institutions make them well-positioned to invest in affordable housing.

The Urban Institute surveyed nonprofit hospitals to learn more about current practice and motivations, considerations, and challenges they face in addressing housing needs of their patients and communities.

“To our knowledge, our survey was a first attempt to systematically understand how nonprofit hospitals and health systems are approaching housing-related activities, including investments,” says Kathryn Reynolds, policy program manager for the Research to Action Lab at the Urban Institute.

Overall, 45 nonprofit hospitals and health systems participated in the survey. Due to the small number of study participants, some experiences and insights may not have been captured, and findings are not generalizable and representative. “However,” Reynolds says, “these findings resonated well in our subsequent roundtable discussions with experts and hospital administrators and gave us some sense of the information and tools that may be needed to encourage more nonprofit hospitals and health systems to consider housing investments.”

Nonprofit hospitals are largely aware of housing needs in their communities or within their patient population and many hospitals are undertaking efforts to address the issue.

Hospitals see housing as a platform for addressing social determinants of health but are concerned about the time and resources needed.

Hospitals most often dedicate health services, administrative capabilities, and political leverage to support housing initiatives.

Hospitals seem less interested in direct financial investments in housing.

Hospitals that are involved in affordable housing development most often provide funding, but at modest levels.

Hospitals that make affordable housing investments partner with financial intermediaries.

Hospitals may need more information about the implications of federal policies for housing investments.

 highlight health systems and hospitals that have made early, innovative investments in community development and housing.

“However, little is known about the nonprofit hospitals and health systems that are exploring or starting to implement housing-related projects, or what could help motivate the hospitals and health systems that are not involved to make housing investments,” Reynolds says. “Further, federal, state, and local funding to create, preserve, and operate affordable apartments falls far short of the need across the country, leading to a shortage of affordable and quality housing, especially for low- and moderate-income families.

“Non-profit hospitals and health systems, as anchor institutions rooted in place and with missions to improve community health, are well-situated to contribute funding to alleviate this problem,” she says.

The Urban Institute publication provides guidance to hospitals and health systems that wish to invest in affordable housing development projects. The resource shares actionable, research-informed strategies and examples of how nonprofit hospitals and health systems can help fill the financing gap that often prevents affordable housing from being built or rehabilitated. The guide describes key steps to consider when planning and implementing an investment strategy:

Assess social determinants of health in the community.

Identify the target population or community for housing investment.

Engage with the community who will be directly impacted.

Understand the policy context that drives the institution’s investment actions.

Determine an affordable housing investment strategy.

Select an implementation partner or partners to assist in reaching the goal.

Three concrete ways in which hospitals and health systems can support a housing investment project, include:

 or swapping land with a housing developer;

Using their financial position to enhance credit

 or lowering borrowing costs, or provide a direct loan for construction, renovation, or rehabilitation costs; and

 to encourage others to invest in affordable housing development. 

There are three things health care executives should know, according to Reynolds:

Affordable housing is a proven asset class with a demonstrated history of predictable returns and a well-developed network of developers and intermediaries

. An investment in housing allows health institutions to serve their mission and address upstream social determinants of health while allowing the hospital to make subsequent investments in future projects with “revolving” dollars, according to Reynolds.

Nonprofit hospitals and health systems have institutional assets that make them especially well-suited to making investments in affordable housing

, especially with a knowledgeable partner, such as a community development financial institution or a non-profit developer. These assets include:					

Financial assets for charitable investments, such as endowments, pensions, and insurance reserves;

Non-financial assets that can be used to offset costs for development, such as land and buildings; and

Their financial strength which can enhance credit or reduce risk of investments.

Evaluation is a critical component to measuring success in any project

, “but our survey and conversations with many hospital and health system administrators suggest that few housing investments-including those designed with specific health outcomes in mind-are systematically tracked and measured,” she says. “An evaluation would not only allow hospital leadership to understand the impact of their investment on patients and communities, but would also contribute to knowledge base of ‘what works’ to alleviate population or community-based housing-related issues.”

How nonprofit hospitals and health systems are getting involved with housing.

How Can Hospitals Invest in Affordable Housing?

, the full-service pharmacy benefits management division of Magellan Health, Inc., today released its fourth annual 

, developed through in-depth data analysis and supported by Magellan’s experience in managing fee-for-service (FFS) Medicaid pharmacy programs.

The report outlines emerging and innovative state strategies for managing high-cost Medicaid prescription drugs. The report also includes a forecast of the top key conditions in Medicaid along with a pipeline analysis of drugs expected to impact the Medicaid program.

Key findings in this year’s report include:

Specialty net trend of 6.1%, up slightly over last year, continued to contribute positively to the overall net trend, but is well below the 20.5% net trend seen in 2016.

Traditional net trend declined from -5.1% in 2016 to -2.6% in 2018. Even with the negative trend, it is not declining at the same pace as the previous two years.

The average net cost per claim was nearly flat at 0.8% change, compared to -4.4% in 2017.

Magellan Rx’s new analytics product, MRx Predict, shows the overall gross trend is expected to marginally rise from 2018 as new, groundbreaking therapies and specialty drugs continue to create upward pressure.

Generics of Older Drugs Could Have Saved Medicare Billions, Study Says

 is an effective tool in providing states with data and solutions to better manage cost trends and improve budget predictability for their Medicaid FFS pharmacy benefit management program,” says Doug Brown, vice president and chief strategy officer, government markets, Magellan Health. “The report examines drug classes with the largest effect on Medicaid net spend, cost-saving opportunities, and a detailed look at how recent legislative and state program innovation has and will affect the Medicaid program.”

New report outlines innovative state strategies for managing high-cost Medicaid prescription drugs.

Report Details Trends in Medicaid Fee-for-Service Pharmacy Programs

Costs for oncology medications continue to increase in the U.S, with spending on all drugs reaching almost 

Journal of Managed Care & Specialty Pharmacy

, there are challenges for managing cancer drug costs even with new innovative technology tools. There are a variety of direct costs associated with treating cancer, which include physician visits, laboratory and imaging tests, radiation treatment, hospital stays, home care, and medication expenses. This article will discuss oncology drugs that are in phase 3 development and biosimilars on the horizon, as well as the financial impact of these medications.

There are a variety of phase 3 drugs in the pipeline with some innovative approaches to cancer treatment. Celgene is planning to submit the biologics license application for lisocabtagene maraleucel (liso-cel) in the fourth quarter of 2019 for diffuse large B-cell lymphoma, the most common type of non-Hodgkin Lymphoma (NHL), with more than 18,000 individuals diagnosed annually. The ongoing phase 3 TRANSFORM (NCT03575351) trial is evaluating liso-cel in patients with B-cell NHL, and the expected study completion date is 2023.

Entinostat is being studied by Syndax Pharmaceuticals for the treatment of advanced hormone receptor-positive breast cancer, which has a novel mechanism of action as a histone deacetylase (HDAC) inhibitor. Evidence suggests that HDAC inhibitors can inhibit tumor growth, result in cancer cell death, and have little effect on normal tissue. Entinostat received Breakthrough Therapy status from the FDA after a phase 2 randomized placebo-controlled study demonstrated significant improvement in overall survival in combination with exemestane vs exemestane as monotherapy. Entinostat is currently being studied in a phase 3 trial (NCT02115282) including about 600 patients with recurrent hormone receptor-positive breast cancer, and the results are expected sometime in 2019.

Novartis is currently studying asciminib in patients with chronic myeloid leukemia through a phase 3 multicenter trial, with results expected in 2025. Asciminib has a novel mechanism of action in that it binds to a different site of the protein than tyrosine kinase inhibitors (TKIs) called the ABL1 myristoyl pocket, making it a promising option for patients that are intolerant/resistant to currently available TKIs.
	 

The Latest in the Hepatitis B Drug Pipeline

Biosimilar drugs and implications in therapy

Biosimilar approval may help to decrease oncology drug costs for patients as patent expirations of major biologics occur. According to Express Scripts, biosimilars could bring approximately $250 billion in savings by 2024. “Biologics have revolutionized oncology treatment modalities available to patients with serious health conditions in the last two decades,” says Jorge J. Garcia, PharmD, assistant vice president/System Oncology Pharmacy Service Line, Miami Cancer Institute/Baptist Health South Florida. Garcia says that biosimilars are defined as biologic agents that are not chemically identical, but are highly similar to an approved reference biologic agent.

Filgrastim-sndz, the first biosimilar FDA-approved and launched in the U.S., “has achieved and maintained market share in its drug class, providing discounts in the vicinity of 30%,” Garcia says. Long-acting granulocyte colony stimulating factor (G-CSF) biosimilars have most recently entered the market (e.g., pegfilgrastim-cbqv and pegfilgrastim-jmdb) driving discounts on highest cost G-CSF products. Additionally, there are more pegfilgrastim biosimilars expected to enter the market in the future, which could potentially further drive down costs.

“Bevacizumab-awwb and trastuzumab-anns are the first oncology therapeutic biosimilars to launch in the U.S. this summer, both of which are expected to make a significant dent on the oncology cost curve,” Garcia says. However, it is anticipated that providers will be more reluctant to use therapeutic biosimilars compared to supportive care biosimilars (e.g., G-CSF).  More significant cost savings are expected as several other bevacizumab and trastuzumab biosimilars enter the U.S. market in the near future. 

Jennifer Gershman, PharmD, CPh is a pharmacist and medical writer residing in South Florida.

Phase 3 drugs show innovative approaches to cancer treatment.

Biologics Build Oncology Drug Pipeline

Cincinnati Children’s Hospital Medical Center

 has called Avondale, Ohio, home since 1926. The hospital has been on a decades-long mission to lead, advocate, and collaborate in order to improve the health of local children and reduce health disparities in targeted populations.

Two such population groups were the focus of a health initiative aimed at reducing the inpatient bed-day rate by at least 10% by mid-2020 for children from two nearby neighborhoods, and to narrow the gap between those neighborhoods and healthier ones.

“This was not a simple or straightforward program,” says the initiative’s lead researcher Andrew F. Beck, MD, attending physician, Division of General & Community Pediatrics and Division of Hospital Medicine at the health system. “Rather, it was complex, involving active collaboration with community partners.”

Beck and fellow researchers explored common elements that underpin morbidity across conditions and serve as key contributors to hospital days and disparities. This focus allowed them to bring the right hospital resources and community partners to the table to tackle the most problematic conditions.

The multi-level approach involved analyzing real-time EHRs to identify neighborhood “hot spots” in need of additional support for children living within those neighborhoods; optimizing chronic disease management by closing care gaps during hospitalizations and after discharge; mitigating social risks such as housing instability and limited access to medications and personal hygiene supplies; and helping children transition out of the hospital. The researchers hoped to develop, test, and refine a theory for how to narrow equity gaps across broader geographic areas.

There were exact improvements within each of these domains.  First, we engineered the EHR to send us alerts every morning if any child from the target neighborhoods was admitted.  This prompted a multi-disciplinary huddle for learning purposes to explore what could have prevented, care gap closure to look into preventive solutions during the hospitalization, like immunizations, and consideration of transition needs (e.g., follow up appointments, medications).  Second, we placed focus on common chronic conditions that were disproportionately contributing to bed-days.  For instance, we have pursued work with our asthma patients to ensure that they have controller medications prior to exacerbation seasons.  We also looked at the distribution of RN and social work care managers to ensure that they were connected with our most at-risk patients.  Third, we have worked with community partners to assess for patterns in social risks.  For instance, we have actively sought to identify building complexes that need broader advocacy and not just patient-level work.  When we identified resource limitations, we actively worked with the local food bank to start an in-clinic food pantry to deliver food into the neighborhood and bolster access to hygiene supplies.

Societal factors influence health outcomes


	In many neighborhoods like Avondale and Price Hill, access to pharmacies, grocery stores, green spaces, and adequate transportation can be limited. Housing may have exposures known to adversely affect health (e.g., pests, mold). This constellation of social, economic, and environmental factors influences short- and long-term health outcomes at the patient level, researchers say.

“We manage about 95% of all pediatric hospitalizations for children living in the county and nearly 100% of children in those neighborhoods,” Beck says. “Child hospitalization rates are high in those neighborhoods and are likely driven by a combination of social, economic, and environmental factors, so we set out to foster healthier communities where it was most urgently needed.”

The Impact of Care Coordination on Caregivers

Beck and his team defined a goal in spring 2015: to reduce the inpatient bed-day rate for children from Avondale and Price Hill by at least 10% by June 30, 2020. Meeting this goal required being accountable for an entire population and focusing on the root causes of place-based inequities, he says.

Improvement efforts began in July of that year, with the assembly of a multidisciplinary team that included inpatient and outpatient medical providers, social workers, community partners (such as legal aid), and parents of neighborhood children.

This initiative focused on roughly 8,000 children living in the high-morbidity, high-poverty Avondale and Price Hill neighborhoods. Children from these communities disproportionately experienced morbidity across nearly every condition and pediatric subspecialty.

The study period was between July 2012 and June 2018, with July 2012–June 2015 as the baseline phase and July 2015–June 2018 as the improvement phase.

Across the entirety of the study period there were a total of 38,583 hospitalizations for in-county children, of which 37,337 (97%) lasted less than 14 days. Hospitalizations that met diagnostic and length-of-stay inclusion criteria contributed 76,759 inpatient bed-days. The county’s inpatient bed-day rate was 5.6 days per 1,000 children per month.

The baseline rate for Avondale and Price Hill was 8.4 days per 1,000 children per month. This equated to neighborhood children collectively spending about 75 days each month and 900 days each year on inpatient units in Cincinnati Children’s Hospital Medical Center before improvement efforts began in the summer of 2015.

By the end of the study period in 2018, the average monthly inpatient bed-day rate decreased to 6.9 per 1,000 children, or 18% fewer in-hospital days than at baseline (July 2012–June 2015). There was no similar decrease in the rate for control neighborhoods, . where the rate remained at 7.6 inpatient bed-days per 1,000 children per month throughout the study period.

The rate reduction in Avondale and Price Hill was likely driven by fewer hospitalizations instead of shorter lengths-of-stay. The hospitalization rate dropped 20%-from 4.1 events per 1,000 children per month to 3.3 events-again beginning during the summer of 2015.

Finally, researchers assessed the degree to which the efforts narrowed equity gaps relative to the rest of the county. For the baseline period, Avondale had the fourth-highest and Price Hill the 11th-highest inpatient bed-day rates out of 80 county neighborhoods. In that period, Avondale and Price Hill children spent 2,720 days in the hospital, compared to 2,145 in the improvement period (July 2015–June 2018). The number of hospitalizations decreased from 1,344 to 1,041. Indicative of a move toward equity, Avondale improved to the ninth-highest and Price Hill to the 15-highest inpatient bed-day rates.


	Beck says he and his team have been encouraged by the marked, statistically significant improvements in Avondale and Price Hill when comparing two key metrics from the 2012-2015 benchmark to their results in 2015-2018: the inpatient bed-day rate and hospitalizations.

“This meant children spend hundreds of additional days at school and at home instead of in the hospital,” Beck says.

While they are pleased with the results, there is still progress to be made, Beck says. “We are taking what we have learned from our efforts in Avondale and Price Hill into account as we plan for scale and spread across additional local neighborhoods. We believe that the theories and methods used to decrease bed-day rates and hospitalizations could serve as a relevant example to other pediatric population health improvement projects-locally as well as nationally.”

 were recently published in Health Affairs.

Tricia Krizner is a Cleveland-based writer.

How one hospital is combatting neighborhood-specific problems.

Population Health Initiative Reduces Pediatric Hospitalization Rate

The race to decrease drug costs is heating up across America. The Trump Administration has one idea, House Majority Leader Nancy Pelosi has her solution and Big Pharma has prosed a resolution to the problem. But some insurers are now rising to the occasion and finding ways for members to afford expensive specialty drug treatments, such as gene therapy.

The cost of gene therapies is expected to reach 

 in the United States by 2024. While only two therapies have yet to be approved, they are indicative of the high price tag.

Luxturna (voretigene neparvovec-rzyl), the first FDA-approved prescription gene therapy for people with inherited retinal disease leading to blindness, costs $415,000 per eye. Zolgensma (onasemnogene abeparvovec-xioi) for children under two years old with spinal muscular atrophy is set at $2.1 million.

These potentially life-saving medications would undoubtedly break the bank and prevent coverage and access by patients.

Cigna has developed a coverage program, Embarc Benefit Protection, for the two therapies that don’t require any out-of-pocket payments related to the cost of the medicine. It is expected to go live by January 2020.

Payers pay a per-member per-month (PMPM) fee to access Embarc’s gene therapy network. Physicians are required to submit prior authorization requests for patient eligibility. Steve Miller, MD, chief medical clinical officer for Cigna, hopes that PMPM will reach $1.

Miller says that Cigna chose gene therapy because of the integral part it will play in overall healthcare. He also is concerned by the history of gene therapies, two of which were approved in Europe and have since been taken off the market because they are cost prohibitive.

“Without patient access, a product can become a tremendous market failure,” Miller says. “Some plans are writing policies to exclude gene therapy, while stop-loss insurers are capping their exposure. Although gene therapy is not yet urgent or presenting any threat, we want to capture the market before insurers decide to exclude these treatments from their benefits.”

He wants to eliminate all barriers to joining the Embarc coalition of subsidiaries and affiliates so that patients are not forced into government insurance. The program initially will target Cigna members followed by Express Scripts’ book of business, then EviCor and finally non-affiliated health plans. 

Brian Duffant, vice president at BluePath Solutions, a market access and health economics/outcomes research consulting firm based in Los Angeles, says payers are developing new payment programs to address the projected future increase in demand for gene therapies based on the burgeoning gene therapy pipeline.

The addressable market for gene therapies could grow as large as 2.4 billion patients worldwide, according to Guggenheim Securities.

Miller says Embarc will combine Cigna’s innovative payment with the health services, medical benefit management, and specialty pharmacy expertise of Express Scripts, a pharmacy benefits manager; eviCore, a healthcare management company; Accredo specialty pharmacy; and Curascript SD, a specialty pharmaceutical dispensing and distribution company.

AveXis, a subsidiary of Novartis Corp. that developed Zolgensma, also is partnering with Cigna’s coalition members offering payers pay-over-time options up to five years and outcomes-based agreements up to five years for the drug. In the same vein, the Cigna partnership will envelop Spark Therapeutics, the producer of Luxturna.

Increasing Access to Gene Therapies Requires Innovative Payment Approaches

“There wasn’t a paradigm in the private sector for this kind of coverage, but we wanted to get something out there,” Miller says.

Cigna chose an approach that considers the impact Embarc will have on all stakeholders, including manufacturers, providers, payers, and patients.

Limits on barriers to access, eliminating the need for copayments

Patient encouragement to make the best choice without financial support playing a role

Cigna anticipates providing best prices and value-based pricing, keeping the price of Zolgensma for example, within the range of traditional cost-effectiveness thresholds used by the Institute for Clinical and Economic Review (ICER)-not just what the market will bear, Miller says. ICER produces cost-effectiveness analyses.

For payers-employers, insurers, and unions-Embarc expects to provide low prices with pass-through and transparency; spread overhead among as many patients as possible; use uniform utilization management criteria so there is no adverse selection, which gives payers 100% predictability; and establish a flat PMPM not based on usage.

Cigna will enable payers to use Embarc as a white label, payment product to build Cigna’s coalition, Miller says.

Patients should receive speedy treatment without any copayments, while providers are expected to be part of centers of excellence to keep costs down.

Miller says patients will pay little-perhaps an administrative fee-to nothing for the new available gene therapies. By negotiating best prices with manufacturers, he anticipates it will be possible to buy down copayments.

“What is clear is that payers will likely use a combined approach to manage gene therapy utilization, including use of centers of excellence; population risk-pooling; and short- and long-term, outcomes- based contracts with manufacturers, reinsurance, and programs intended to pay for gene therapy over time as opposed to one up-front payment,” Duffant explains.

 developed by the PwC Health Research Institute (HRI) outlines a menu of contracting and price-assistance models that could make gene therapy more accessible and affordable.

HRI, however, found in a survey that just 56% of pharmaceutical executives reported using at least one value-based drug contract, while only 14% of payers said they engaged in outcomes-based agreements with biopharmaceutical companies.

Cigna is working on version two of Embarc that will target patients most likely to benefit from gene therapy to limit adverse risk. “The product will begin to look more traditional as more patients are involved and prices decrease,” Miller says.

Duffant is concerned that if a small employer has even one patient who needs gene therapy, this could have a catastrophic impact on employers’ overall healthcare spend. “Payers need a way to manage a new paradigm of gene therapies with a high one-time upfront cost and uncertain clinical benefits over the long-term,” he says.

“While some of the populations eligible for gene therapies may be relatively small compared to other therapeutic areas, gene therapies generally address clear areas of unmet medical need and have short-term data as proof of evidence in select patient populations,” Duffant says. “The key question is whether gene therapies can deliver the promise of long-term health benefits for patients, and we are simply too early in the game to see if this will be true.”

Steve Wojcik, vice president, public policy, National Business Group on Health, believes that programs like Embarc sound like an installment finance option versus a one-time expense to cover gene therapies. “They should provide more predictability for employers and can spread payment over a period of time,” he says.

He recommends using clinical management tools to target the right persons with the right therapies.

Although it is a new way of financing specialty pharmacy and gene therapy, it doesn't get to the challenge posed by these expensive drugs; it doesn't address long-term sustainability and is out of line with economic and wage growth,” Wojcik says. “It is similar to covering college expenses while not addressing inflation.”

He concedes that patients are shielded from cost sharing, but acknowledges an underlying payment exists. He is concerned that smaller employers are apt to face higher premiums to offset the pricing arrangement. “There are already limits on OOP payments,” Wojcik says.

While he doesn’t expect a big impact initially with these payment programs, he believes that as more gene therapies hit the marketplace and affect a wider population, the result could have more significance and provide affordable healthcare.

Other insurers to jump on coverage bandwagon

Ethan Slavin, spokesperson for Aetna, says the insurer is working hard to effectively manage the cost of these therapies for its clients and members. For example, Aetna is currently developing:

Refined pharmacy benefit management strategies, including formulary and utilization management programs, for therapy classes with high-cost entrants that have available alternatives.

Stop-loss products for clients looking to better control medical costs, including an innovative reinsurance instrument specifically designed for gene therapies.

Alternative payment models, including annuity payments that spread the cost of ultra-high cost drugs over a period of time, and may provide some clients with options to control spending in a single year.

The heath plan also is exploring outcomes-based contracts with manufacturers to ensure patients and customers derive clinical benefit and value from gene therapy products. In addition, Aetna is advancing a network strategy that ensures patients receive treatment at high-value sites of care in terms of both clinical quality and cost.

 published by the Advisory Board, Anthem has a product under consideration that includes reimbursement or stop-loss options that would protect employers from the negative financial repercussions of gene therapies.

Payers are finding ways for members to afford expensive specialty drug treatments.

Accessibility and Affordability of Gene Therapy

Cancer-related pain doesn’t always stop when active treatment ends. Patients with stabilized disease or in remission are living longer due to earlier detection and better treatments. Managing chronic pain (six months or longer) is increasingly important. About 

5% of the U.S. population are cancer survivors, 15.5 million people

, according to “Pain in Cancer Survivors: How to Manage,” June 2019, 

. Cancer-related pain can be from the disease itself, or due to treatment. Most cancer patients will experience pain at some point during their illness, says Jacob Strand, MD, chair of palliative care medicine at the Mayo Clinic in Rochester, Minnesota. About 80% to 90% of those with metastases, who are incurable, will have cancer-related pain, Strand says, as will up to 

Ideally, treating pain involves a multi-prong approach. That might mean some combination of physical therapy, behavioral therapy, blocks/injections, and medication. Not all health insurance covers an extensive approach, though undertreating pain impacts a patient’s health and quality of life substantially. As patients live longer after active treatment, oncologists see the patients less, leaving pain management in the hands of primary care physicians (PCP), who may not feel equipped to treat it.

A typical assessment for pain management includes pain assessment, functional assessment, and then risk assessment, says Judith Paice, PhD, RN, director of the Cancer Pain Program in the Hematology-Oncology division at Northwestern University in Chicago.

The risk assessment is newer and still not performed by most oncologists, Paice says. It includes questions about smoking, alcohol use, and prescription substance use not as prescribed. It also includes a family history of substance abuse to give a “crude understanding of genetic risk” and to understand what substance issues might exist in the home. She takes all the answers into account, while trying to determine if their pain is likely to respond to opioids, and if they’re at risk for abuse.

Managing Chronic Conditions at Home: Boston Scientific’s Connected Patient Challenge Calls for Digital Innovations

A cancer patient can suffer from various types of pain. Tumor-related pain can be from a tissue injury, like a mass effect from the tumor pressing against the bone or nerves. Pain can be treatment-related, like pain after surgery, or associated with radiation therapy. As radiation gets more precise, patients are experiencing less pain. “Unfortunately, pain associated with chemotherapy is increasing, as more and more agents are causing peripheral neuropathy,” Paice says. Steroid use can cause avascular necrosis and bone fragility. Aromatase inhibitors and hormonal therapies for prostate and breast cancers can cause pain. “If one in eight women with breast cancer are estrogen positive, they’re likely on aromatase inhibitors for five to 10 years,” Paice says. Stem cell transplant can lead to graft versus host disease. With new treatments always arising, pain management is a moving target, she says.

Assessing and treating function, not pain severity

Pain used to be assessed and treated based on intensity scores, with patients rating their pain on a 0-10 scale, and trying to lower the pain to a different number. That is changing. Clinicians are now focused on functionality, what the patient can do after pain management that they couldn’t do before it. Clinicians ask patients about their physical and emotional goals, understanding what improved function and quality of life looks like.

Improved functionality could be performing activities of daily living that they can’t do because of pain, Strand says. “That shift is particularly important in chronic cancer-related pain, where there’s no cure for the underlying problem,” he says.

Multimodal therapy is the preferred approach. While medications work well for some, a medication may be contraindicated due to a patient’s other medical issues. And not all pain can be addressed with pharmacological treatments. Treatments like physical and occupational therapy, and cognitive behavioral therapy (CBT) are often helpful, though CBT sometimes carries a stigma. “I try to reframe it,” Paice says. She tells patients “our psychologist here is not for crazy people. It’s for normal people going through crazy times.” She tells them they are going through a difficult time, but have an inner strength that the therapist will help them find.

The idea behind using multiple interventions is to provide the best outcomes with the fewest side effects and least risk. Not all therapy types are indicated for each patient, but it’s important to consider different treatment modes. In the best scenario, patients have access to various therapies to help them move appropriately and with emotions. “It’s really tough to get all of that paid,” Paice says.

Five years out from cancer treatment, many patients are no longer seeing their oncologist more than once annually, if at all. Some academic medical centers develop care plans for PCPs to follow, but they mostly recommend screening practices, not pain management. That can leave PCPs in the uncomfortable position of treating cancer-related pain, without the knowledge.

“Clinicians have historically not been well trained to manage cancer pain at all stages of their diagnosis, illness, survivorship, and end of life,” Strand says. With a significant patient population with growing health needs, it’s important for all physicians and advanced practice providers to get pain management training.

Palliative care clinicians tend to see more difficult cases, Strand says, either those with a complicated medication regimen, or patients with coexisting symptoms like mood disorders, or patients with a high risk of relapse.

One concern that cancer patients have is the fear of cancer recurrence. A new pain complaint is stressful to patients, given the uncertainty of the disease returning. A clinician treating a cancer survivor for pain should be aware of that.

Clinicians try to optimize use of non-opioid medications for chronic pain, Paice says. That can include nonsteroidal anti-inflammatory drugs. Steroid injections and nerve blocks are useful, especially for abdominal pain related to pancreatic cancer, says David Craig, PharmD, clinical pharmacist in pain management/palliative care at H. Lee Moffit Cancer Center in Tampa, Florida. “Drugs are not very good at managing abdominal or neuropathic pain,” he says.

But 30% to 50% of those getting antineoplastic therapy, and 75% to 90% 

of those with advanced disease, have pain best treated by opioids, according to UpToDate, topic updated June 2019. Opioids have received a lot of negative press lately. “Our first goal as physicians is to do no harm,” Strand says. And that means being thoughtful about how medications are used and how patients are monitored, to minimize even unintentional harm.

Not only are some clinicians reticent to prescribe opioids when indicated, but patients are afraid to take them. “We need to be really direct and ask them if they’re worried about becoming addicted,” Paice says. Patients may not take prescribed opioids out of fear, or because they receive negative messages from family members. That contributes to undertreatment of pain.

Part of Strand’s risk screening process includes checking the state prescription monitoring database, to see if the patient may be at risk for substance abuse. Closely monitoring outcomes and patient function, as opposed to pain level, helps with safer prescribing. “We can provide it safely and still manage pain effectively,” Strand says. He tells patients that part of his job is to make sure they’re safe, and that can help overcome some fear of addiction. The number of patients in his practice who benefit from opioid treatment far outweigh the number of patients harmed from it, he says. Monitoring patients with opioid prescriptions is labor intensive, requiring close communication with oncology and PCP colleagues. “Opioids for all” is not an appropriate strategy, but they’re helpful for some patients.

Clinicians disagree about the utility of cannabis in pain management. Craig does not recommend it to his patients, as he says there’s not enough data to support it, and patients think they can buy it from someone off the street, smoke it, and it will work. “We don’t disallow it, but we don’t recommend it,” he says.

, “Medical Oncologists’ Beliefs, Practices, and Knowledge Regarding Marijuana Used Therapeutically: A Nationally Representative Survey Study,” in the Journal of Clinical Oncology reported that up to 80% of oncologists have discussed medical cannabis use with patients, though only 30% felt informed enough to recommend it. The study, which surveyed 400 medical oncologists in 2016, showed that 67% of oncologists thought it was a helpful addition to standard pain management options. 

 noted that some studies found that inhaled marijuana was helpful for neuropathic pain, and that those using marijuana extracts in clinical trials needed less pain medication.

Strand has comprehensive discussions with his patients about medical cannabis, as he knows patients will ask about it. He says the data on effectiveness in pain management for cancer pain is mixed. In his practice he’s seen patients benefit from it, and those who don’t. Like many treatments, clinicians need to determine how cannabis fits into treatment, and monitor it closely for side effects. “They’re not the savior to our problems with pain, but they should also not be discarded,” he says. Before a patient uses cannabis for pain management, he asks them to track it in a pain diary, just as they would with any other pain medication.

Undertreating pain is a problem, as is overtreatment. Pain management allows a person to be functional. “They need to move to prevent lung complications, blood clots, and improve their general quality of life,” Paice says. “We don’t want people isolated in their homes because the pain is too bad to move.” This happens due to access to care, as well as for those afraid to use opioids.

Undertreatment can also affect survival. “Sometimes symptoms that are poorly controlled can lead patients to discontinue therapy,” Strand says. He tells patients that if their pain is preventing them from getting out of their chair, they’ll have a worse outcome than if they were functional individuals.

Deborah Abrams Kaplan covers medical and practice management topics. 

There are a variety of ways, but a multi-pronged approach is best.

Approaches to Cancer Pain Management

As such, both payer and provider organizations are looking for creative, sustainable ways to reduce waste and improve the quality of care for patients, especially those who are living with chronic or complex medical conditions. With CMS already collecting data for its first oncology performance measure, 

OP-35: Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy

, which will affect payments come 2020, many healthcare organizations are taking a long, hard look at where they can prevent, or at least significantly reduce, cancer readmissions.

It’s not a surprise. As noted by the Agency for Healthcare Research and Quality (AHRQ), hospital readmissions, regardless of condition, are remarkably expensive, with collective costs hovering just over $41 billion a year for patients who return to the hospital within 30 days of discharge. But Alok Khorana, MD, a medical oncologist at the Cleveland Clinic, says readmissions are becoming more of a focal issue for cancer care, as more patients are treated in an outpatient setting.

“In the past, cancer patients were generally admitted while they were worked up, staying in the hospital for 10 to 14 days,” he explains. “Today, there is pressure to make hospital stays as brief as possible, which means that many patients are discharged without all of their issues being completely resolved. Since cancer is such a complex condition, with both acute and chronic elements, we often see that readmission rates in the cancer population are higher than those in the general medical population.”

But given cancer’s complexity, what can healthcare stakeholders across the industry do to better prevent cancer readmissions?

Given how little time patients stay in the hospital today, the Cleveland Clinic embarked on a process improvement project to improve outpatient care transitions. Khorana says the project started as a way of looking at “common sense” steps to reduce readmissions. He said their first lesson learned what that a significant portion of cancer readmissions are simply inevitable given this disease’s level of complexity.

As more healthcare organizations look to curb hospital readmission rates, they are taking a hard look at one of medicine’s most complex conditions-cancer.

MHE November 2019

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