Reimbursement

Faced with new government regulations, Medicare Advantage (MA) organizations should be utilizing technology to increase the accuracy of their coding, mitigate their risk, and ensure appropriate care for members.

We are in the midst of a transformative time in oncology that could also be a little scary if you are not prepared, said Nicolas Ferreyros, managing director of policy, advocacy, and communications, Community Oncology Alliance.

Medicare’s administered pricing system has never had to deal with labor scarcity before.

The AHEAD Model will operate for 11 years and aim to shift health care to community-based settings.

Specialty pharmacy is a big area of growth, with opportunity for patients, and specialty pharmacists can help payers and insurers ensure that patients get the full value of oncology medications, noted Andre Harvin, PharmD, MS, MBA, chief pharmacy officer, Oncology Services, Cone Health Cancer Centers.

Care quality is high in both the United States and Canada, but there are commonalities in regard to drug access and cost issues, particularly with advanced medications, noted G. B. John Mancini, MD, University of British Columbia.

The Medicare Shared Savings Program (MSSP) generated its second highest annual savings since the program began more than a decade ago.

Physicians have been facing increasing workloads making it difficult to practice medicine as they were trained, but an accountable care organization might provide an opportunity for real change to deliver high-value, compassionate care.

The 10 drugs, spanning disease states from diabetes to heart failure to rheumatoid arthritis, cost Medicare enrollees a total of $3.4 billion in out-of-pocket costs in 2022. As required by the Inflation Reduction Act (IRA), negotiations between Part D and pharmaceutical companies will take place this year and next, with the negotiated prices taking effect in 2026.

Patients and physicians are publicly shaming insurance companies on social media for the troublesome prior authorization process; HHS has awarded $1.4 billion in grants for the creation of new technologies and tools to prevent COVID-19 infection; Novo Nordisk has increased lobbying efforts to allow Medicare coverage of weight loss drugs.

Some hospitals were able to outperform others in a commercial insurer episode-based incentive program, but there was little evidence of global reductions in episode spending.

In a large, integrated health system participating in value-based care, higher costs and utilization were observed before and after unplanned dialysis initiation.

The revisions to the ACO REACH model are expected to add predictability and stability while advancing health equity.

Olalekan Ajayi, PharmD, MBA, 2023-2024 president of the Association of Community Cancer Centers, discusses what practices should do to succeed under the Enhancing Oncology Model (EOM).

The program, which scales an accountable care organization (ACO) model across all major payers in Vermont, reduced Medicare spending and hospitalizations while improving patient care.

Hospitals and health systems have been operating in the most challenging financial environment in history, and now they face another looming headwind—the impact of Medicaid redeterminations.

Physicians and health care groups have lined up to support the Value in Health Care Act, which could create new incentives to adopt value-based care.

The playbook from the 3 organizations highlights 5 best practices for data sharing from organizations with real-world experience in value-based care arrangements.

The proposed fee schedule for 2024 would reduce payments by 3.4%. Most responses were swift and negative.

The Enhancing Oncology Model (EOM) attracted more than 2800 practitioners across 561 sites of care; a group of practices in the American Oncology Network enrolled under a single tax ID number.

After the Supreme Court ruled reimbursement cuts to 340B hospitals were done unlawfully, CMS is proposing to repay hospitals and providers in the program with a lump sum that has repercussions for other hospitals because of the agency’s need to be budget neutral.

While the final number of EOM practices will be fewer than the numbers in the OCM, the presence of Tennessee Oncology, Texas Oncology, and Northwest Medical Specialties will ensure participation of key leaders who succeeded in the OCM and have weighed in on what's needed in its replacement.

Speakers elaborated on health care delivery and regulatory policy posters presented at the 2023 American Society of Clinical Oncology (ASCO) Annual Meeting. This article will appear in the ASCO recap edition of Evidence-Based Oncology.

Ahead of tonight's deadline for practices to decide whether to join the Enhancing Oncology Model, CMS published a list of participants that is already outdated. A possible flaw in the model's breast cancer methodology has some practices weighing their options.

Officials note it could slow acquisition of physicians’ offices, but hospitals bristle at prospect.

The health plans, which have announced their intent to join forces, retired $345,000 in debt in the areas they serve.

The Enhancing Oncology Model, announced in July 2022 during the final days of its predecessor, the Oncology Care Model (OCM), has a similar framework as the early alternative payment model for oncology in Medicare, but there are key differences in reimbursement and especially in practices’ requirements to take on risk.

With Medicare-aged Americans accounting for over 15% of the population and significant health care costs, stakeholders have leveraged various approaches, including the Medicare Current Beneficiary Survey, for estimating costs.

Deemed the “Medicare” effect, patients aged 65 years who have Medicare coverage had an increased incidence of head and neck squamous cell carcinoma (HNSCC) but were less likely to receive a late-stage diagnosis and had lower mortality rates.