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Medicare's Drug-Pricing Experiment Stirs Opposition Print E-mail
Written by Julie Appleby | KHN   
Monday, 30 May 2016 00:00

khn logo black A broad proposal by Medicare to change the way it pays for some drugs has drawn intense reaction and lobbying, with much of the debate centering on whether the plan gives too much power over drug prices to government regulators.
 
One of most controversial sections would set up a nationwide experiment, scheduled to start in 2017, to test a handful of ways to slow spending on drugs provided in doctor's offices, clinics, hospitals and cancer infusion centers. The proposal would not affect most prescriptions patients get through their pharmacies.
 
The aim, the government says, is to maintain quality while slowing spending in Medicare Part B by more closely tying payments to how well drugs work, using methods drugmakers, insurers and benefit managers are already trying in the private sector.
 
One of the approaches included in the proposal would allow Medicare to earmark "therapeutically similar" drugs and set a benchmark, or "reference price," that it would pay for all drugs in that category. That amount might be the cost of the drug the agency considers the most effective in the group, or some other measure. It's aimed at narrowing the wide variability - often hundreds or thousands of dollars a year - in what is paid for similar drugs.
 
Such an approach is seen by some as government price setting, a method common in Europe that draws support in the U.S. from the left but has longstanding opposition from conservatives, many economists and pharmaceutical companies.
 
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MACRA rules for physician payments stacked against small practices, critics say Print E-mail
Written by Jeff Lagasse | Healthcare Finance   
Wednesday, 04 May 2016 00:00

About 346,000 physicians, mostly in practices that have between one and 24 members, could see penalties.
 
Proposed regulations released last week by the Centers for Medicare and Medicaid Services are raising concerns that the playing field is uneven, with 87 percent of solo practitioners getting penalized and 81 percent of clinicians in large groups earning bonuses, according to some estimates.
 
The new proposal includes a compensation formula for Medicare that gives performance bonuses as high as 4 percent to about 412,000 physicians and other clinicians in 2019, according to published reports. But there will also be penalties on an additional 346,000, mostly in practices that have between one and 24 members.
 
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Last Updated on Tuesday, 10 May 2016 11:25
 
Examining CMS' proposed cancer drugs pilot Print E-mail
Written by Carolyn Johnson | The Washington Post   
Tuesday, 12 April 2016 00:00

A controversial effort by the Obama administration to reform how doctors earn money from administering injection drugs would reduce their earnings on the most expensive drugs while making many older generics more lucrative, according to a new analysis.

A high-stakes debate exploded last month over the administration's drug payment pilot program, which would test a fundamental change in how doctors are reimbursed for giving chemotherapy and other injectable drugs through Medicare. Medicare has said the pilot would remove a perverse incentive for doctors to prescribe the most expensive drugs, while the drug industry, doctors and disease groups argue it would threaten small cancer practices and seniors' health.

The opposition to the pilot shared by drug companies and doctors -- parties that don't always see eye-to-eye on drug prices -- led Peter Bach, director of the Center for Health Policy Outcomes at Memorial Sloan Kettering Cancer Center to look more closely at how the policy would affect reimbursements...

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Last Updated on Wednesday, 13 April 2016 14:37
 
CMS proposes new payment model for Medicare Part B Print E-mail
Written by The Health Law Offices of Anthony C. Vitale   
Tuesday, 05 April 2016 17:32

The Centers for Medicare and Medicaid Services (CMS) is proposing a new rule that could result in a new Medicare Part B drug payment model. Published in the Federal Register, the agency is proposing a two-phase model that would test whether alternative drug payment designs would result in a reduction in Medicare costs, while at the same time preserve, or even enhance, the quality of care for Medicare beneficiaries.

Under the existing methodology, expensive drugs receive higher add-on payment amounts than less expensive drugs, while there are no clear incentives for providing high-value care, including drug therapy. It's hoped that under the new model providers would be incentivized to prescribe the most effective drugs and link payments to patient outcomes.

"We hope that the revised pricing will remove any excess financial incentive to prescribe high cost drugs over lower cost ones when comparable low cost drugs are available," writes CMS. "In other words, we believe that removing the financial incentive that may be associated with higher add-on payments will lead to some reduction in expenditures during phase I of the proposed model."
 
Last Updated on Tuesday, 05 April 2016 17:35
 
Program Integrity Changes to the Medicare Provider Enrollment Process Print E-mail
Written by MWE.com   
Thursday, 17 March 2016 00:00

On March 1, 2016, the U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services (CMS) published a proposed rule (Proposed Rule) entitled "Medicare, Medicaid, and Children's Health Insurance Programs; Program Integrity Enhancements to the Provider Enrollment Process". The Proposed Rule addresses Medicare, Medicaid and Children's Health Insurance Program (CHIP) enrollment and revalidation reporting requirements, as well as expanded CMS authority intended to increase program integrity through the Medicare enrollment process.  CMS is accepting public comments on the Proposed Rule until May 1, 2016.

In response to concerns that certain providers and suppliers were able to evade federal health care program integrity provisions by changing names or establishing complex entity relationships, the Affordable Care Act incorporated additional requirements in Section 1866(j)(5) of the Social Security Act for disclosure of certain information at enrollment and revalidation intended to identify such relationships before enrolling and making payments to entities that would not otherwise be eligible for enrollment.  The Proposed Rule seeks to implement the requirements of Section 1866(j)(5), as well as provide CMS with additional authority related to denial or revocation of Medicare enrollment and imposition and extension of Medicare reenrollment bars.

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