CMS has announced its plans to evaluate a new value-based payment model for prescription drugs covered under the Part B program. This is yet another move by the federal body to ensure quality care for Medicare enrollees.
CMS has announced its plans to evaluate a new value-based payment model for prescription drugs covered under the Part B program. This is yet another move by the federal body to ensure quality care for Medicare enrollees.
Medicare Part B covers prescription drugs that are administered in a physician’s office or hospital outpatient department, such as cancer medications, injectables like antibiotics, or eye care treatments. These drugs usually fall into 1 of 3 categories:
The new model being proposed will support clinical decisions as providers choose the drug that is right for their patients, the emphasis being on choosing the most effective or high-value drugs, and providing incentives/rewards for improved outcomes. Beginning late 2016, the proposed model will test whether changing the add-on payment to the average sales price from 6% to 2.5% plus a flat fee payment of $16.80 per drug per day changes prescribing incentives.
“First and foremost, our job is to get beneficiaries the medications they need. These proposals would allow us to test different ways to help Medicare beneficiaries get the right medications and right care while supporting physicians in the process,” said Andy Slavitt, acting administrator for CMS, in a statement. “This is consistent with our focus on testing value-based care models like we have been doing with physicians and hospitals in ACOs. Models like this one can help doctors and other clinicians do what they do best: choose the medicine and treatment that keeps their patients healthy.”
CMS has proposed 6 alternative approaches on pricing strategies for Part B drugs that emphasize value-based purchasing. These include:
CMS plans to test the model for a period of 5 years, with the incentive and value-based purchasing tests fully operational during the last 3 years to monitor changes and gather enough evidence. Success of the model will be gauged based on net reductions in Medicare spending without compromising on coverage or benefits, while maintaining or improving patient care. CMS will launch a concurrent real-time claims monitoring program to track utilization, spending, and prescribing patterns as well as changes in site of service delivery, mortality, hospital admissions, and several other high-level claims-based measures.
“These models would test how to improve Medicare beneficiaries’ care by aligning incentives to reward value and the most successful patient outcomes,” said Patrick Conway, MD, MSC, deputy administrator for Innovation and Quality and chief medical officer of CMS, in a statement. “The choice of medications for beneficiaries should be driven by the best available evidence, the unique needs of the patient, and what best promotes high quality care.”
Examining Low-Value Cancer Care Trends Amidst the COVID-19 Pandemic
April 25th 2024On this episode of Managed Care Cast, we're talking with the authors of a study published in the April 2024 issue of The American Journal of Managed Care® about their findings on the rates of low-value cancer care services throughout the COVID-19 pandemic.
Listen
Navigating Health Policy in an Election Year: Insights From Dr Dennis Scanlon
April 2nd 2024On this episode of Managed Care Cast, we're talking with Dennis Scanlon, PhD, the editor in chief of The American Journal of Accountable Care®, about prior authorization, price transparency, the impact of health policy on the upcoming election, and more.
Listen
Prices for care at hospital trauma centers vary across hospitals; drug shortages reached a record high during the first quarter of 2024; although 3 of the biggest makers of asthma inhalers pledged to cap out-of-pocket costs for some US patients at $35, these do not apply to daily inhalers used by the youngest kids with asthma.
Read More
Commonwealth Fund Report Details Pervasive Racial and Ethnic Disparities in US Health Care, Outcomes
April 18th 2024Using 25 health system performance indicators, the Commonwealth Fund 2024 State Health Disparities Report evaluated racial and ethnic disparities in health care and health outcomes both within and across US states and highlighted the urgent need for equitable health care policies and practices in the US.
Read More