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Archive for the ‘Accountable Care Organizations’ Category


CMS initiative in Modernizing Medicare to lead to Lower Prescription Drug Costs

Reporter: Aviva Lev-Ari, PhD, RN

 

CMS Takes Action to Lower Prescription Drug Costs by Modernizing Medicare

 

     

CMS Takes Action to Lower Prescription Drug Costs by Modernizing Medicare 
Proposed regulation for Medicare Parts C & D would strengthen negotiations with prescription drug manufacturers to lower costs and increase transparency for patients

Today, the Centers for Medicare & Medicaid Services (CMS) proposed polices for 2020 to strengthen and modernize the Medicare Part C and D programs. The proposal would ensure that Medicare Advantage and Part D plans have more tools to negotiate lower drug prices, and the agency is also considering a policy that would require pharmacy rebates to be passed on to seniors to lower their drug costs at the pharmacy counter.

“President Trump is following through on his promise to bring tougher negotiation to Medicare and bring down drug costs for patients, without restricting patient access or choice,” said HHS Secretary Alex Azar. “By bringing the latest tools from the private sector to Medicare Part D, we can save money for taxpayers and seniors, improve access to expensive drugs many seniors need, and expand their choice of plans. The Part D proposals complement efforts to bring down costs in Medicare Advantage and in Medicare Part B through negotiation, all part of the President’s plan to put American patients first by bringing down prescription-drug prices and out-of-pocket costs.”

In the twelve years since the Part D program was launched, many of the tools outlined in today’s proposal have been developed in the commercial health insurance marketplace, and the result has been lower costs for patients. Seniors in Medicare also deserve to benefit from these approaches to reducing costs, so today CMS is proposing to modernize the Medicare Advantage and Part D programs and remove barriers that keep plans from leveraging these tools.

“In designing today’s proposal, foremost in the agency’s mind was the impact on patients, and the proposal is yet another action CMS has taken to deliver on President Trump and Secretary Azar’s commitment on drug prices,” said CMS Administrator Seema Verma. “Today’s changes will provide seniors with more plan options featuring lower costs for prescription drugs, and seniors will remain in the driver’s seat as they can choose the plan that works best for them. The result will be increasing access to the medicines that seniors depend on by lowering their out-of-pocket costs.”

Private plan options for receiving Medicare benefits are increasing in popularity, with almost 37 percent of Medicare beneficiaries expected to enroll in Medicare Advantage in 2019, and Part D enrollment increasing year-over-year as well. The programs are driven by market competition; plans compete for beneficiaries’ business, and each enrollee chooses the plan that best meets his or her needs. Consumer choice puts pressure on plans to improve quality and lower costs.  Premiums in both Medicare Advantage and Part D are projected to decline next year.

Today’s proposed changes include:

  • Providing Part D plans with greater flexibility to negotiate discounts for drugs in “protected” therapeutic classes, so beneficiaries who need these drugs will see lower costs;
  • Requiring Part D plans to increase transparency and provide enrollees and their doctors with a patient’s out-of-pocket cost obligations for prescription drugs when a prescription is written;
  • Codifying a policy similar to the one implemented for 2019 to allow “step therapy” in Medicare Advantage for Part B drugs, encouraging access to high-value products including biosimilars; and
  • Implementing a statutory requirement, recently signed by President Trump, that prohibits pharmacy gag clauses in Part D.

CMS is also considering for a future plan year, which may be as early as 2020, a policy that would ensure that enrollees pay the lowest cost for the prescription drugs they pick up at a pharmacy, after taking into account back-end payments from pharmacies to plans.

Medicare Advantage and Part D will continue to protect patient access, as both programs are embedded with robust beneficiary protections. These include CMS’s review of Part D plan formularies, an expedited appeals process, and a requirement for plans to cover two drugs in every therapeutic class.

CMS looks forward to receiving comments on these proposals and other policies under consideration.

For a blog post on the proposed rule by Secretary Azar and Administrator Verma, please visit: https://www.cms.gov/blog/proposed-changes-lower-drug-prices-medicare-advantage-and-part-d.

For a fact sheet on the proposed rule, please visit: https://www.cms.gov/newsroom/fact-sheets/contract-year-cy-2020-medicare-advantage-and-part-d-drug-pricing-proposed-rule-cms-4180-p.

The proposed rule (CMS-4180-P) can be downloaded from the Federal Register at: https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-25945.pdf

###

Get CMS news at cms.gov/newsroom, sign up for CMS news via email and follow CMS on Twitter CMS Administrator @SeemaCMS

SOURCE

https://www.cms.gov/newsroom/press-releases/cms-takes-action-lower-prescription-drug-costs-modernizing-medicare?mc_cid=ca8901d1c5&mc_eid=32328d8919

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 Through Data Science: Stanford Medicine and Google will transform Patient Care and Medical Research

Reporter: Aviva Lev-Ari, PhD, RN

 

Stanford Medicine integrates research, medical education and health care at its three institutions –Stanford University School of Medicine, Stanford Health Care (formerly Stanford Hospital & Clinics), and Lucile Packard Children’s Hospital Stanford. For more information, please visit the Office of Communication & Public Affairs site at http://mednews.stanford.edu.

 

Stanford’s forthcoming Clinical Genomics Service, which puts genomic sequencing into the hands of clinicians to help diagnose disease, will be built using Google Genomics, a service that applies the same technologies that power Google Search and Maps to securely store, process, explore and share genomic data sets.

The Clinical Genomics Service will enable physicians at Stanford Health Care and Stanford Children’s Health to order genome sequencing for patients who have distinctive or unusual symptoms that might be caused by a wayward gene. The genomic data would then go to the Google Cloud Platform to join masses of aggregated and anonymous data from other Stanford patients. “As the new service launches,” said Euan Ashley, MRCP, DPhil, a Stanford associate professor of medicine and of genetics, “we’ll be doing hundreds and then thousands of genome sequences.”

The Clinical Genomics Service aims to make genetic testing a normal part of health care for patients. “Genetic testing is built into the whole system,” said Ashley. A physician who thinks a genome-sequencing test could help a patient can simply request sequencing along with other blood tests, he said. “The DNA gets sequenced and a large amount of data comes back,” he said. At that point, Stanford can use Google Cloud to analyze the data to decide which gene variants might be responsible for the patient’s health condition. Then a data curation team will work with the physician to narrow the possibilities, he said.

“This collaboration will enable Stanford to discover new ways to advance medicine to the benefit of Stanford patients and families,” said Ed Kopetsky, chief information officer at Lucile Packard Children’s Hospital Stanford and Stanford Children’s Health. “Together, Stanford Medicine and Google are making a major contribution and commitment in curing diseases that afflict children not just in our community, but throughout the world. It’s an extraordinary investment, and we’re proud to play such a large role in transforming patient care and research.”

Read more at the SOURCE

 

Stanford Medicine, Google team up to harness power of data science for health care

By JENNIE DUSHECK

Jennie Dusheck is a science writer for the medical school’s Office of Communication & Public Affairs. Email her at dusheck@stanford.edu.
SOURCE

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CMS releases MACRA rule proposal: Will HHS force physicians to drop fee for service for fee for outcome?

Streamlined implementation aims to increase flexibility, decrease reporting burden for physicians

The U.S. Department of Health and Human Services unveiled a proposed ruletackling the initial implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

According to an HHS announcement accompanying the rule, the primary aim is to simplify and streamline the existing patchwork of value-based payment models that have increasingly replaced the traditional fee-for-service system via a new framework dubbed the Quality Payment Program. This structure provides doctors with two paths for compliance:

The Centers for Medicare & Medicaid Services expects most providers to opt for the MIPS track initially, according to CMS Acting Principal Deputy Administrator and Chief Medical Officer Patrick Conway, M.D., who spoke on a conference call announcing the rule.

Participation in Advanced Alternative Payment models would exempt doctors from MIPS reporting requirements while also qualifying them for financial bonuses in exchange for taking on the risks related with providing “coordinated, high-quality care,” according to CMS. The agency expects both the number of physicians participating in this track and the number of payment models available to grow over time.

CMS also reports that doctors will have the flexibility to switch among various components of the Quality Payment Program as dictated by the needs of their patients or their practices.

Opinions from around the web

In this video, Gilberg, senior vice president for the Medical Group Management Association’s Government Affairs Office, discusses CMS’ Physician Value-based Payment Modifier. In 2015, Medicare will begin applying the modifier under the physician fee schedule to various providers to show value of care.

“Cost and quality … make up the value equation, in the mind of the payer, in terms of Medicare,” said Gilberg.

In addition to explaining how the modifier works, Gilberg also highlights other quality measures facing providers under the Physician Quality Reporting System and via the EHR Incentive Programs, better known as meaningful use.

View Video at

http://www.physicianspractice.com/mgma14/understanding-medicare-value-based-payment-models

When the Medicare Access and CHIP Reauthorization Act (MACRA) legislation passed in April 2015, everyone cheered the repeal of the Sustainable Growth Rate (SGR) formula for Medicare physician payment. Now, even before the MACRA regulations are even promulgated, it’s time to pay attention because Medicare physician payments in 2019 will be impacted by their performance in 2017, just a year from now.

Other related articles

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April 28, 2016
 

Dr. Foti Recognized With Honorary Member Award from Oncology Nursing Society

Margaret Foti, PhD, MD (hc), chief executive officer (CEO) of the American Association for Cancer Research (AACR), was honored this morning during the opening ceremony of the 41st Annual Congress of the Oncology Nursing Society (ONS) in San Antonio, TX, with the Honorary Member Award for her unwavering dedication to improving cancer care and her commitment to the prevention and cure of all cancers.
The Honorary Member Award is awarded by the ONS to thank and honor an individual who is not otherwise eligible for ONS membership for his or her contributions to oncology nursing, support of the ONS, and conduct consistent with the ONS mission and core values.

 

LEARN MORE
ABOUT THE AACR

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Mayo Clinic in Rochester, Minnesota – Pinnacle in Medical Innovations: A Model to The National HealthCare – the EMR Revolution

Reporter: Aviva Lev-Ari, PhD, RN

Charlie Rose interview with John Noseworthy, President and CEO of the Mayo Clinic in Rochester, Minnesota, 12/1/2014.

VIEW VIDEO

CEO, Mayo Clinic, John Noseworthy interviewed by Charlie Rose

 

Another case Study in Excellence in HealthCare Management – 

Leading the way: Scripps Health CEO takes hands-on approach to frontline staff engagement

Fierce exclusive: Chris Van Gorder discusses leadership rounds, onboarding and relationship building

http://www.fiercehealthcare.com/story/leading-way-scipps-health-ceo-takes-hands-approach-frontline-staff-engageme/2015-04-09?page=full

 

Leaders in Pharmaceutical Business Intelligence

has covered the HealthCare Reform in the following seminal articles that were published in 2014 in this Open Access Online Scientific Journal:

2.0 The Cost to Value Conundrum in Cardiovascular Healthcare Provision

Larry H. Bernstein, MD, FCAP

2.1 Cost of Care for Cardiovascular Medical Diagnoses

 

2.1.1 Diagnosis of Cardiovascular Disease, Treatment and Prevention: Current & AHA Predicted Cost of Care and the Promise of Individualized Medicine Using Clinical Decision Support Systems

Justin Pearlman, MD, PhD, FACC, Larry H Bernstein, MD, FACP, and Aviva Lev-Ari,PhD, RN

 

2.1.2 Economic Toll of Heart Failure in the US: Forecasting the Impact of Heart Failure in the United States – A Policy Statement From the American Heart Association

Aviva Lev-Ari, PhD, RN

 

2.1.3 Heart Disease: Economic and Personal Effects

Reporter: Aviva Lev-Ari, PhD, RN

 

2.2 Impact of 2013 HealthCare Reform in the US

 

2.2.1 The Affordable Care Act: A Considered Evaluation. Part I.  The legislative act (ACA) and the model for implementation (Insurance Gateways).

Larry H. Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN

 

2.2.2 The Affordable Care Act: A Considered Evaluation. Part II: The Implementation of the ACA, Impact on Physicians and Patients, and the Dis-Ease of the Accountable Care Organizations.

Larry H. Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN

 

2.2.3 The Affordable Care Act: A Considered Evaluation.
 Part III. Final Implementation of the Affordable Care Act and a Patient and Community Outcomes Focus

Larry H Bernstein, MD, FCAP

 

2.2.4 Post Acute Care – Driver of Variation in Healthcare Costs

Larry H. Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN

 

2.3 Patient Protection and Affordable Care Act Featured at RAND

Aviva Lev-Ari, PhD, RN

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Photo

Dr. Peter Eisenberg, left, said people with less money were treated differently by doctors.
Credit Preston Gannaway for The New York Times

When Dr. Jeffery Ward, a cancer specialist, and his partners sold their private practice to the Swedish Medical Center in Seattle, the hospital built them a new office suite 50 yards from the old place. The practice was bigger, but Dr. Ward saw the same patients and provided chemotherapyjust like before. On the surface, nothing had changed but the setting.

But there was one big difference. Treatments suddenly cost more, with higher co-payments for patients and higher bills for insurers. Because of quirks in the payment system, patients and their insurers pay hospitals and their doctors about twice what they pay independent oncologists for administering cancer treatments.

There also was a hidden difference — the money made from the drugs themselves. Cancer patients and their insurers buy chemotherapy drugs from their medical providers. Swedish Medical Center, like many other others, participates in a federal program that lets it purchase these drugs for about half what private practice doctors pay, greatly increasing profits.

Oncologists like Dr. Ward say the reason they are being forced to sell or close their practices is because insurers have severely reduced payments to them and because the drugs they buy and sell to patients are now so expensive. Payments had gotten so low, Dr. Ward said, that they only way he and his partners could have stayed independent was to work for free. When he sold his practice, Dr. Ward said, “The hospital was a refuge, not the culprit.”

When a doctor is affiliated with a hospital, though, patients end up paying, out of pocket, an average $134 more per dose for the most commonly used cancer drugs, according to a report by IMS Health, a health care information company. And, the report notes, many cancer patients receive multiple drugs.

“Say there was a Costco that had very good things at reasonable prices,” said Dr. Barry Brooks, a Dallas oncologist in private practice. “Then a Neiman Marcus comes in and changes the sign on the door and starts billing twice as much for the same things.” That, he said, is what is happening in oncology.

Chemotherapy drug

Pertuzumab (breast cancer)
Rituximab (lymphoma, leukemia)
Bevacizumab (several cancers)
Cetuximab (head, neck, colorectal)
Trastuzumab (breast, stomach)
Fulvestrant (breast)
Leuprolide Acetate (prostate)
Epirubicin (breast)
Interferon alfa-2B (lymphoma, others)
Mitoxantrone (prostate, leukemia)
Doxorubicin (leukemia, others)
Goserelin (prostate, breast)
Daunorubicin (leukemia)
Idarubicin (leukemia)
Mitomycin C (stomach, pancreas)

Sources: IMS Institute for Healthcare Informatics; RxList
By The New York Times

A Quirk in Drug Pricing

Insurers pay hospitals and doctors affiliated with hospitals more to adminster chemotherapy drugs than they pay independent doctors.

 

Insurance reimbursment per dose in a hospital or hospital-affiliated office Reimbursment per dose in a private practice

Chemotherapy drug

(and some cancers it can treat)

SEE FIGURE in article

http://www.nytimes.com/2014/11/24/health/private-oncologists-being-forced-out-leaving-patients-to-face-higher-bills.html?_r=0

The situation is part of the unusual world of cancer medicine, where payment systems are unique and drive not just the price of care but what drugs patients may get and where they are treated. It raises questions about whether independent doctors, squeezed by finances, might be swayed to use drugs that give them greater profits or treat poorer patients differently than those who are better insured.

But one thing is clear: The private practice oncologist is becoming a vanishing breed, driven away by the changing economics of cancer medicine.

Practices are making the move across the nation. Reporting on the nation’s 1,447 independent oncology practices, the Community Oncology Alliance, an advocacy group for independent practices, said that since 2008, 544 were purchased by or entered contractual relationships with hospitals, another 313 closed and 395 reported they were in tough financial straits. In western Washington, just one independent oncology group is left.

Christian Downs, executive director of the Association of Community Cancer Centers, said that although there are no good data yet, he expected the Affordable Care Act was accelerating the trend. Many people bought inadequate insurance for the expensive cancer care they require. Community doctors have to buy the drugs ahead of time, placing a burden on them when patients cannot pay. The act also requires documentation of efficiencies in medical care which can be expensive for doctors in private practice to provide. And it encourages the consolidation of medical practices.

The American Hospital Association cites advantages for patients being treated by hospital doctors. “The hassle factor is reduced,” said Erik Rasmussen, the association’s vice president of legislative affairs. Patients can have scans, like CT and M.R.I., use a pharmacy and get lab tests all in one place instead of going from facility to facility, he said.

And, he added, there is a reason hospitals get higher fees for their services — it compensates them for staying open 24 hours and caring for uninsured and underinsured patients.

For doctors in private practice, providing chemotherapy to uninsured and Medicaid patients is a money loser. As a result, many, including Dr. Ward before he sold his practice, end up sending those patients to nearby hospitals for chemotherapy while keeping them as patients for office visits.

“We hate doing it, I can’t tell you how much we hate doing it,” said Dr. Brooks, the Texas oncologist. “But I tell them, ‘It will cost me $200 to give you this medication in my office, so I am going to ask you to go to the hospital as an outpatient for infusions.’ ”

Dr. Peter Eisenberg, in private practice in Marin County in Northern California, said: “The disgrace is that we have to treat people differently depending on how much money they’ve got. That we do diminishes me.”

Hospitals may be less personal and less efficient, said Dr. Richard Schilsky, chief medical officer at the American Society of Clinical Oncology. Many private practice oncology offices, he said, “Run on time, they are efficient, you get in, you get out, as opposed to academic medical centers where they may be an hour and a half behind.”

Dr. Ward and others in private practice said they tried for years to make a go of it but were finally defeated by what he described as “a series of cuts in oncology reimbursement under the guise of reform to which private practice is most vulnerable.”

Lower reimbursements have two effects. One is on overhead. Unlike other doctors, oncologists stock their own drugs, maintaining a sort of mini-pharmacy. If a patient gets too sick to receive a drug or dies, the doctor takes the loss. That used to be acceptable because insurers paid doctors at least twice the wholesale price of drugs. Now doctors are reimbursed for the average cost of the drug plus 4.3 percent, there are more and more drugs to stock, and drugs cost more.

“The overhead is enormous,” Dr. Schilsky said. “This is one of the reasons why many oncologists are becoming hospital-based.”

The second — and bigger — effect is less profit from selling drugs to patients. For years, chemotherapy drugs provided a comfortable income. Those days are gone, doctors say.

The finances are very different in hospitals, with their

  • higher reimbursement rates for administering drugs,
  • discounts for buying large quantities, and
  • a special federal program that about 30 percent of hospitals qualify for.
  • The program, to compensate research hospitals and hospitals serving poor people,
  • lets hospitals buy chemotherapy drugs for all outpatients at about a 50 percent discount.

In addition, Dr. Schilsky notes, cancer patients at hospitals use other services, like radiation therapy, imaging and surgery.

“A cancer patient is going to generate a lot of revenue for a hospital,” Dr. Schilsky said.

Health care economists say they have little data on how the costs and profits from selling chemotherapy drugs are affecting patient care. Doctors are constantly reminded, though, of how much they can make if they buy more of a company’s drug.

Celgene, for example, in a recent email about its drug Abraxane, told one doctor who had bought 50 vials that he could get a rebate of $647.51 by buying 68 vials. If he bought 175 vials he’d get $1,831.93

This hidden profit possibility troubles Dr. Peter B. Bach, director of the Center for Health Policy and Outcomes at Memorial Sloan Kettering Cancer Center.

“When you walk into a doctor’s office you don’t know that in most cancer scenarios there are a range of therapeutic choices,” Dr. Bach said. “Unless the doctor presents options, you assume there aren’t any.”

While individual oncologists deny choosing treatments that provide them with the greatest profit, Dr. Kanti Rai, a cancer specialist at North Shore-Long Island Jewish Cancer Center, said it would be foolish to believe financial considerations never influence doctors’ choices of drugs.

“Sometimes hidden in such choices — and many times not so hidden — are considerations of what also might be financially more profitable,” he said.

A version of this article appears in print on November 24, 2014, on page A13 of the New York edition with the headline: Private Oncologists Being Forced Out, Leaving Patients to Face Higher Bills. 
SOURCE 

http://www.nytimes.com/2014/11/24/health/private-oncologists-being-forced-out-leaving-patients-to-face-higher-bills.html?_r=0 

 

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2:15PM 11/13/2014 – 10th Annual Personalized Medicine Conference at the Harvard Medical School, Boston

REAL TIME Coverage of this Conference by Dr. Aviva Lev-Ari, PhD, RN – Director and Founder of LEADERS in PHARMACEUTICAL BUSINESS INTELLIGENCE, Boston http://pharmaceuticalintelligence.com

 

 

2:15 p.m. Panel Discussion Reimbursement/Regulation

 

Reimbursement and Regulation

     Moderator:

Sheila D. Walcoff, J.D.
CEO and Founder, Goldbug Strategies, LLC

Panelists:

2. Catalina Lopez Correa, M.D., Ph.D.
Vice President/CSO, Scientific Affairs
Génome Québec

1. Michael Kolodziej, M.D.
National Medical Director for Oncology Strategies, Aetna

Clinical Utility Test is done cheap the drug used as therapeutics is $10,000 – without knowing if it will work or not

3. Bruce Quinn, M.D., Ph.D.
Senior Health Policy Specialist
Foley Hoag LLP

It is a whole ecosystem,

1. CMS – ACA

2. On diagnostics: clinical utility (six questions), clinical validity, analytical

$50 test kit from Abbott, 20,000 patients – $1 million market for test, Drug: $100,000 = $1 Billion for Pharma

Test coverage by Insurance:
  • If Patient sign Risks are known, Physician is educated, Patient is educated by Physician
  • Participation in Registry — test is covered
  • making information actionable to the Consumer

See more at: http://personalizedmedicine.partners.org/Education/Personalized-Medicine-Conference/Program.aspx#sthash.qGbGZXXf.dpuf

 

@HarvardPMConf

#PMConf

@SachsAssociates

@GenomeQuebec

@clopezcorrea

@Aetna (for Dr. Kolodziej)

 

@FoleyHoag (for Bruce Quinn)

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