Reimbursement

The Inflation Reduction Act (IRA) may be restricting Medicare Part D formularies, increasing patient costs, and stifling pharmaceutical innovation, experts warned at the Academy of Managed Care Pharmacy 2025 annual meeting.

Debra Patt, MD, PhD, MBA, executive vice president of Public Policy and Strategy for Texas Oncology, said the practice received positive feedback from nurses and patients during a pilot that concluded in February.

Jorge García, PharmD, MS, MBA, MHA, highlights the need for infusion pharmacy optimization to sustain oncology care amid rising costs and evolving value-based reimbursement models.

The design of the Enhancing Oncology Model (EOM) was a perfect fit for Minnesota Oncology.

Independent pharmacies have filed 3 class action lawsuits against GoodRx Holdings and major pharmacy benefit managers (PBMs).

CMS is creating infrastructure to improve coverage of prescription digital therapeutics (PDTs), and new legislation would also drive uptake of PDTs.

Stuart Staggs, vice president of transformation and shared services at McKesson, explained that oncology practices in the Enhancing Oncology Model (EOM) have a tough job driving down costs when drug costs make up a larger portion of the total cost of care.

CMS made improvements for the Enhancing Oncology Model (EOM) over the Oncology Care Model (OCM), but there remains a delay in data and the challenge of high-cost, novel therapies, explained Stuart Staggs, vice president, Transformation and Shared Services, McKesson.

A new letter signed by more than 230 members of the House urges Congress to not only block the scheduled 2.8% reimbursement cut, but also reform the Medicare Physician Fee Schedule.

Lalan Wilfong, MD, a 20-year medical oncologist with Texas Oncology, is senior vice president, value-based care, Thyme Care.

After a small number of practices joined the Enhancing Oncology Model (EOM) in 2023, CMS has made some changes and opened the model back up for new practices to join.

Hospital care transition activity facilitates uptake of Medicare-reimbursed transitional care management, which is associated with lower spending and better patient outcomes.

Based on an Avalere Health report, Community Oncology Alliance warns that IRA negotiations could slice down payments needed to administer cancer drugs.

The transition to value-based care is extremely challenging because everyone is also still being paid by fee for service, said Lalan Wilfong, MD, senior vice president, value-based care, Thyme Care.

The findings may help inform policy changes at the federal level aiming to address unfair and deceptive pharmacy benefit manager (PBM) practices.

There are concerns that the negotiated drug prices under the Inflation Reduction Act (IRA) are leading to large provider reimbursement cuts, explained Nick Ferreyros, managing director, Community Oncology Alliance.

A comparative analysis investigating time from a drug's approval to insurance reimbursement found that the speed of this process in the US falls behind some European countries.

Analysis of 2012-2021 commercial claims demonstrates that spending growth was concentrated among the highest spenders and there was increasing subsidy across enrollees through cost-sharing design.

Katherine Baker, MD, MMHC, of Tennessee Oncology, highlights the need for physician-payer collaboration to tackle challenges and drive innovation in specialty care.

National data sets and registries are able to provide outcomes data and process measures that testify to quality of care being delivered, said Matthew Nielsen, MD, FACS, chair, Department of Urology, University of North Carolina School of Medicine.

Strategies to help Medicare Advantage plans boost Star Ratings by improving medication adherence among seemingly “unengageable” members

Some groups praised CMS after it announced the 10 negotiated Medicare drug prices while others criticized its potential impacts on drug competition and development.