MACRA: A Stepping-Stone for Broader Changes

Posted by Christina Corridon on Dec 11, 2017 12:00:00 PM

Howard Deutsch co-wrote this blog post with Christina Corridon.

In its current form, the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA) of 2015 directly impacts the reimbursement rates and methodology of the physician fee schedule under Medicare Part B. However, MACRA is unlikely to have a significant impact on physician behavior or drug choice. Nonetheless, MACRA is part of a larger transition of payment based on volume to payment based on value (quality and cost reduction). Physicians will be penalized for continuing with “business as usual,” and newfound attention to tracking and reporting outcomes will be rewarded.


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How to Pay for Transformative Cell and Gene Therapies

Posted by Bernadette Bourjolly on Oct 13, 2017 8:00:00 AM

Malik Kaman co-wrote this blog post with Bernadette Bourjolly. 

After two decades of failures and setbacks, it’s an exciting time in the field of cell and gene therapies as we witness pioneering advances in a wide range of indications in areas including blood cancers, immunodeficiency and ophthalmology. While cell and gene therapies represent a potential paradigm shift for the treatment of cancer and rare genetic disorders, funding and reimbursement of these unconventional therapies pose major challenges. 


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Which Side Is Right About CMS’ Proposed Part B Drug Reimbursement Model?

Posted by Bill Coyle on Jul 6, 2016 3:46:12 PM

Reactions to the Centers for Medicare and Medicaid Services’ (CMS) proposed Part B drug reimbursement demonstration project have been both swift and predictable. Under the proposal, reimbursement for drugs covered under Part B would be reduced from average sale price (ASP) +6% (pre-sequester) to ASP +2.5% plus a flat fee of $16.80. CMS would also pursue various value-based purchasing tools as part of the pilot. The objective is “to encourage better care, smarter spending, and healthier people by paying providers for what works.”

Not surprisingly, physician groups and the medical societies to which they belong quickly decried the proposal as being potentially dangerous for patients, saying that it would put certain physicians and patients (in the demonstration ZIP codes) at unfair disadvantages to those in the current system.


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Oncology Value Watchdog: What the Medicare Part B Reimbursement Model Means for Patients

Posted by Christina Corridon on Apr 25, 2016 11:41:32 AM


On March 8, 2016, the Centers for Medicare and Medicaid Services (CMS) proposed to test a new Medicare Part B reimbursement model in a “lottery” of sorts, with the goal of delivering more value-driven care. The current incentives for prescribing a Part B drug allow the provider to make a margin of 6% of the average selling price (ASP) of the therapy. For an oncology drug that is infused weekly and costs $10,000 per month, that means $600 of margin per month for the provider. And the more expensive the drug, the higher the margin amount. (Not surprisingly, cancer drugs made up 42.1% of all Medicare Part B spend in 2014, according to CMS.) Under the new model being piloted by CMS, practices that “win” the lottery will now be reimbursed at ASP plus 2.5% and a flat rate payment of $16.80 per treatment, according to the Department of Health and Human Services. So that same $10,000 drug will now only yield $317.20 to the provider—about half of the $600 that they make today. After sequestration, that amount is reduced even further to $152.12.


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Oncology Pathways: Who Controls the Menu at Healthcare’s ‘Dinner for Three’?

Posted by Paul Darling on Mar 21, 2016 8:00:00 AM

In recent years, payers have made an effort to exert more control over physicians’ treatment decisions, especially in oncology. They’ve created clinical pathways that set out treatment guidelines and use prior authorizations and step therapy to encourage physicians to select payers’ preferred protocols and drugs.


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