Reimbursement

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For Community Oncology, Good News in PFS Offset by Potential Wreckage of MFP Proposal

July 15th 2025

CMS proposes the 2026 Physician Fee Schedule (PFS), addressing payment disparities in oncology, but the community oncology community warns of financial threats from the Inflation Reduction Act. Updates reflect late Tuesday release of the proposed 2026 schedule for the Hospital Outpatient Prospective Payment System.

Rise in drug pricing | Image Credit: Alex Puhovoy - stock.adobe.com
Medicare Inflation Rebates Show Limited Impact on Drug Price Trends

July 14th 2025

Image credit: Canva Illustration | Mary Caffrey
Practical Considerations for AI in Community Oncology

July 8th 2025

Image credit: Canva Illustration by Mary Caffrey
How AI Can Address the Troubled Business Model in Oncology

July 7th 2025

Blood sample lab | Image credit: Caris Life Sciences
At ASCO, Testing and AI Rival Drugs for Attention, but Reimbursement Remains a Barrier

July 5th 2025

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April 10th 2023

Population Turnover and Leakage in Commercial ACOs

Nicole M. Benson, MD, MBI Mary Price, MA Christine Vogeli, PhD Maryann M. Vienneau, BS Mallika L. Mendu, MD, MBA Amy Flaster, MD, MBA Lisa Balentine, BASc Lindsay Jubelt, MD, MS Gregg S. Meyer, MD, MSc John Hsu, MD, MBA, MSCE
Payment models that align financial incentives of payers, providers, and patients can mitigate spending growth in thoughtful ways, but the details of the models matter.
insurance coverage depicted through health care services under an umbrella
March 22nd 2023

Building Better Equity-Based Benefit Designs

Laura Joszt, MA
Panelists at the Value-Based Insurance Design Summit discussed ways their organizations are looking to create a better benefit design to promote health equity and address known disparities.
Nicolas Ferreyros, BA, managing director, The Community Oncology Alliance
March 22nd 2023

Nicolas Ferreyros: There Is Growing Recognition the 340B Program Is "Out of Control"

Pearl Steinzor
Growing bipartisan awareness of issues with the 340B drug pricing program will hopefully lead to reform, says Nicolas Ferreyros, BA, managing director of policy, advocacy, and communications at the Community Oncology Alliance.
stethoscope on money
March 21st 2023

Contributor: COVID-19’s Impact on ACO REACH Deserves CMS' Attention

David Pittman, BS Samuel Johnmeyer
CMS must account for inclusion of COVID years in 2023 ACO REACH benchmarks to avoid unfairly penalizing REACH ACOs.
Dr Dennis Scanlon Smiling
February 26th 2023

Dr Dennis Scanlon Discusses What to Be Aware of as Medicare Advantage Programs Grow

Justina Petrullo
Dennis Scanlon, PhD, professor of health policy and administration at the Pennsylvania State University, discusses how expanded benefits in a Medicare Advantage plan can sometimes come with more limited provider networks, and how the Office of the Inspector General is identifying problems in these plans.
Shifting From OCM to EOM: What Stays and What Goes?
February 23rd 2023

Shifting From OCM to EOM: What Stays and What Goes?

Hayden E. Klein
Dr Dennis Scanlon Says More MA Options, Benefits Significantly Reshape Medicare
February 22nd 2023

Dr Dennis Scanlon Says More MA Options, Benefits Significantly Reshape Medicare

Justina Petrullo
Dennis Scanlon, PhD, professor of health policy and administration at the Pennsylvania State University, discusses how extra benefit coverage and the choice to shop for plan options are some factors driving Medicare Advantage (MA) program growth.
State Legislatures Lead the Way on Policy Reform to Protect Personalized Medicine
February 22nd 2023

State Legislatures Lead the Way on Policy Reform to Protect Personalized Medicine

Angela Storseth-Cooper Lalan Wilfong, MD
The Role of Specialty Pharmacies in Improving Prescription Drug Access and Affordability for Consumers
February 22nd 2023

The Role of Specialty Pharmacies in Improving Prescription Drug Access and Affordability for Consumers

Sergio Santiviago, JD Jeanette Thornton, MPA
Fireside Chat: Data, Champions, and Culture Are Keys to Driving Value-Based Care
February 21st 2023

Fireside Chat: Data, Champions, and Culture Are Keys to Driving Value-Based Care

Mary Caffrey
Value-Based Care Asks: Are We Being Kind to Our Patients?
February 21st 2023

Value-Based Care Asks: Are We Being Kind to Our Patients?

Maggie L. Shaw
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February 15th 2023

CMS Practice Assessment Tool Validity for Alternative Payment Models

Malaz A. Boustani, MD, MPH Anthony J. Perkins, MS Mary L. Davis-Ajami, PhD, MBA, MS, FNP-C, RN Kosali I. Simon, PhD Chiang-Hua Chang, PhD Craig A. Solid, PhD Patrick O. Monahan, PhD
Using data from 632 primary care practices, the authors show that the CMS Practice Assessment Tool has adequate predictive validity for participation in alternative payment models.
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February 14th 2023

CMS Outlines 3 New Drug Pricing Models Targeting Wide Scope of Therapies

Allison Inserro
Targeting everyday chronic conditions to rare diseases that require costly, sometimes 1-time treatments, CMS Tuesday announced an intent to test 3 new models in an effort to lower drug prices and widen access to expensive, life-changing therapies for patients in Medicare and Medicaid.
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February 13th 2023

Pediatric Oral Health Services in Medicaid Managed Care and Fee for Service

Annie Yu-An Chen, DDS, MS Isaac M. Opper, PhD Andrew W. Dick, PhD Bradley D. Stein, MD, PhD Ashley M. Kranz, PhD
Rates of preventive oral health services among pediatric medical visits in Florida were similar whether visits were paid via Medicaid comprehensive managed care or fee for service.
Dennis Scanlon, PhD, Professor of Health Policy and Administration, Penn State University
February 12th 2023

Dr Dennis Scanlon Discusses IRA Part D Changes Intended to Expand Access

Justina Petrullo
Dennis Scanlon, PhD, professor of health policy and administration at the Pennsylvania State University, discusses some of the reasoning behind Part D benefits changes in the Inflation Reduction Act (IRA) and the cost questions that remain.
picture of stethoscope on money
February 10th 2023

CMS Releases Guidance on the Math Behind Part B, Part D Drug Rebates

Allison Inserro
The Biden administration released 2 sets of guidance documents for pharmaceutical manufacturers about how it plans to implement the new Medicare Prescription Drug Inflation Rebate Program as required under the Inflation Reduction Act, and said some beneficiaries could see lower coinsurance for some Part B drugs as soon as April 1.
Cancer care costs at the end of life
February 7th 2023

Examining Trends in Outpatient Cancer Costs in Medicare During Last 6 Months of Life

Allison Inserro
Drug costs, particularly for immunotherapies, contributed to the rising cost of care during the last 6 months of life for a fee-for-service Medicare beneficiary, according to a recent study.
Mitch Perry, Senior Vice President, Chief Financial Officer, Blue Cross Blue Shield North Carolina
February 5th 2023

Contributor: For Better or Worse, Inflation Isn’t New to Health Insurers

Mitch Perry
In this column, a health insurance executive discusses 2 ways to address rising inflation, including moving past the traditional fee-for-service payment model.
Image of a dollar sign
February 3rd 2023

Inflation Reduction Act Could Cut Medicare Drug Spending by 5%, Study Suggests

Jared Kaltwasser
The bill could have saved CMS about $26.5 billion had it been in place from 2018-2020, the study showed.
Interview with Dennis Scanlon, PhD
February 1st 2023

Dr Dennis Scanlon Discusses the Impact of the COVID-19 Pandemic on Medicaid Coverage

Justina Petrullo
With the public health emergency soon coming to an end, people covered by Medicaid will encounter new barriers, discusses Dennis Scanlon, PhD, professor of health policy and administration, Penn State University.
graphic illustrating costs
January 31st 2023

Canadian Study Shows Greater Alignment Between Clinical Benefit, Cancer Drug Prices

Allison Inserro
In Canada, monthly prices were significantly different for cancer drugs with substantial clinical benefit vs low benefit.
graphic depicting drug costs
January 30th 2023

IRA Insulin Cap Could Have Saved Medicare Beneficiaries Millions in 2020

Skylar Jeremias
An HHS report said that if the Inflation Reduction Act (IRA) had been implemented in 2020, Medicare Part D beneficiaries could have saved a total of $734 million, averaging out to about $500 per member.
ASH Guideline Champions Detail Ways to Improve Quality and Outcomes, Trim Hospitalizations
January 19th 2023

ASH Guideline Champions Detail Ways to Improve Quality and Outcomes, Trim Hospitalizations

Mary Caffrey
Coverage from the 64th American Society of Hematology Annual Meeting and Exposition, held December 10-13, 2022, in New Orleans, Louisiana.
Adding Social Factors to Risk Adjustment Not Enough to Reach Health Equity, Paper Says
January 12th 2023

Adding Social Factors to Risk Adjustment Not Enough to Reach Health Equity, Paper Says

Rose McNulty
To best improve health equity, population-based payment models should both incorporate social goals and increase payment for historically marginalized communities, a recent study has found.
Ken Cohen Interview
January 12th 2023

Dr Ken Cohen Offers Possible Solutions to Reducing Wasteful Health Care

Laura Joszt, MA Justina Petrullo
Creating new incentive models and transparently sharing data in a way that changes behaviors are 2 ways to reduce low-value care in the health care system, explains Ken Cohen, MD, director of translational research for Optum Care.
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January 11th 2023

Associations Between Physician Practice Models and Health Information Exchange

J. Mac McCullough, PhD, MPH Chad Stecher, PhD
A survey of all Arizona physicians found that accountable care organization, clinically integrated network, or integrated delivery network participation was associated with higher use of health information exchange. However, there are exceptions and important barriers noted.
image representing cost cutting
January 11th 2023

HHS Outlines Timeline to Negotiate Medicare Drug Prices

Allison Inserro
The 10 drugs selected for Medicare Part D price negotiation with HHS will be announced on September 1, 2023, HHS said Wednesday.
Mike Koroscik, MBA, MHA, Allina Health
January 6th 2023

Allina Health’s Mike Koroscik on Helping Patients Navigate Cancer-Related Financial Toxicity

Maggie L. Shaw
We want to make it easy for our patients to manage and navigate the financial toxicity they encounter from their cancer care, noted Mike Koroscik, MBA, MHA, vice president of oncology, Allina Health and the Allina Health Cancer Institute.
top 5 content about reimbursement issues 2022
December 30th 2022

Top 5 Most-Viewed Reimbursement Content in 2022

AJMC Staff
The top 5 pieces of content published on AJMC.com relating to reimbursement issues included 2 on the significance of a California law giving Medicare beneficiaries access to expert oncology care; other articles looked at the work involved in value-based care models and CMS news.
Graphic with the words "The Top 5 The American Journal of Accountable Care articles of 2022"
December 26th 2022

Top 5 AJAC Articles for 2022

AJMC Staff
The top content published in The American Journal of Accountable Care® (AJAC) covered redesigning health care, value-based care, and novel payment models, like the ACO REACH model.
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