Reimbursement

A class action lawsuit was filed against UnitedHealth Group and a subsidiary for allegedly using an algorithm to deny rehabilitation coverage for seriously ill patients; US and China officials are finalizing an agreement to crack down on fentanyl; a study published Tuesday projected global heat deaths to increase by 370% if no action is taken against global warming.

This 2022 survey of Medicare accountable care organizations (ACOs) shows significant growth in non-Medicare value-based contracts and in contracts with downside risk.

The Enhancing Oncology Model is trying to address a number of the systemic challenges oncology faces without giving practices the tools and resources they need, said Nicolas Ferreyros, managing director of policy, advocacy, and communications, Community Oncology Alliance.

This study demonstrates a method for understanding the effects of drug spending in the design of alternative payment models.

Changes in the medication therapy management (MTM) program willl require planning on how to best fund this program in a way that drives medical cost savings.

The Medical Group Management Association offers an analysis of pending legislation that could help health care practices better serve patients.

There is bipartisan support in the Congress for the Community Oncology Alliance's (COA) key agenda items, with hope that some will pass by year’s end.

Community oncology practices are witnessing a new dynamic in which more Medicare-eligible patients are still covered by commercial insurance, according to speakers at the Community Oncology Alliance Payer Exchange Summit, held October 23-24, 2023.

To ensure patients are getting timely access to their treatments, there needs to be better collaboration between payers and providers, said Christine Pfaff, RPh, senior regional director of operations, American Oncology Network.

According to the National Cancer Institute, in the year following a cancer diagnosis, the average cost of medical care plus medication exceeds $42,000, with some treatments having a price tag of more than $1 million.

Cigna will pay $172 million to resolve allegations that it submitted inaccurate diagnosis codes for Medicare Advantage plan enrollees in order to increase payments from Medicare.

The effects of flat or reduced reimbursements alongside inflation have been quantified in a report by Avalere Health, prepared for the Community Oncology Alliance (COA.)

The number one ingredient that an oncology-based alternative payment model needs to succeed is collaboration, explained Nicolas Ferreyros, managing director of policy, advocacy, and communications, Community Oncology Alliance (COA).

Faced with new government regulations, Medicare Advantage (MA) organizations should be utilizing technology to increase the accuracy of their coding, mitigate their risk, and ensure appropriate care for members.

We are in the midst of a transformative time in oncology that could also be a little scary if you are not prepared, said Nicolas Ferreyros, managing director of policy, advocacy, and communications, Community Oncology Alliance.

Medicare’s administered pricing system has never had to deal with labor scarcity before.

The AHEAD Model will operate for 11 years and aim to shift health care to community-based settings.

Specialty pharmacy is a big area of growth, with opportunity for patients, and specialty pharmacists can help payers and insurers ensure that patients get the full value of oncology medications, noted Andre Harvin, PharmD, MS, MBA, chief pharmacy officer, Oncology Services, Cone Health Cancer Centers.

Care quality is high in both the United States and Canada, but there are commonalities in regard to drug access and cost issues, particularly with advanced medications, noted G. B. John Mancini, MD, University of British Columbia.

The Medicare Shared Savings Program (MSSP) generated its second highest annual savings since the program began more than a decade ago.

Physicians have been facing increasing workloads making it difficult to practice medicine as they were trained, but an accountable care organization might provide an opportunity for real change to deliver high-value, compassionate care.

The 10 drugs, spanning disease states from diabetes to heart failure to rheumatoid arthritis, cost Medicare enrollees a total of $3.4 billion in out-of-pocket costs in 2022. As required by the Inflation Reduction Act (IRA), negotiations between Part D and pharmaceutical companies will take place this year and next, with the negotiated prices taking effect in 2026.

Patients and physicians are publicly shaming insurance companies on social media for the troublesome prior authorization process; HHS has awarded $1.4 billion in grants for the creation of new technologies and tools to prevent COVID-19 infection; Novo Nordisk has increased lobbying efforts to allow Medicare coverage of weight loss drugs.

Some hospitals were able to outperform others in a commercial insurer episode-based incentive program, but there was little evidence of global reductions in episode spending.

In a large, integrated health system participating in value-based care, higher costs and utilization were observed before and after unplanned dialysis initiation.

The revisions to the ACO REACH model are expected to add predictability and stability while advancing health equity.

Olalekan Ajayi, PharmD, MBA, 2023-2024 president of the Association of Community Cancer Centers, discusses what practices should do to succeed under the Enhancing Oncology Model (EOM).

The program, which scales an accountable care organization (ACO) model across all major payers in Vermont, reduced Medicare spending and hospitalizations while improving patient care.