Unbiased Analysis of Today's Healthcare Issues
In May 2025, CMS’s Center for Medicare & Medicaid Innovation (CMMI) unveiled it’s “Make America Healthy Again” vision. CMMI models focus on not only “protecting the federal taxpayer,” but also (i) promoting evidence-based prevention, (ii) empowering people to achieve their health goals, and (iii) driving choice and competition for people. CMMI has introduced a number…
This is the question that a recent AJMCcommentary by William Shrank, Ellen Kelsay, and Mark Fendrick aims to answer. When talking about cell and gene therapies, the authors argue that cost sharing is not being used to avoid unnecessary use of low value care, but rather as a form of rationing that creates disparities in…
One approach CMS has is the Cell and Gene Therapy (CGT) Access Model. Under the CGT Access Model, CMS (at the federal level) will negotiates outcomes based agreements (OBAs) with manufacturers, which will include pricing terms and outcomes to be evaluated. Then states can elect to participate in the contract terms negotiated by CMS or…
A paper by Westrich et al. (2023) examines payer perceptions of five different value frameworks. Value frameworks of interest included: American Society of Clinical Oncology (ASCO) Value Framework, Drug Pricing Lab’s Drug Abacus (formerly Memorial Sloan Kettering Cancer Center’s Drug Abacus), Institute for Clinical and Economic Review (ICER) value assessment framework and evidence reports The…
Health Care Payment Learning and Action Network (HCP LAN) is dedicated to moving the health care system from volume-based, fee-for-service reimbursement, to alternative payment models (APM). While there are a large number of different types of APMs, broadly, all of them shift more financial risk to providers while also linking reimbursement to quality of care.…
CMS is increasingly moving to alternative payment models whereby providers are paid based on their ability to improve/maintain quality and hold the line on cost. A key question then, is how does CMS evaluate quality of care? Today, the Healthcare Economist will answer this question for the case of Medicare’s Shared Savings Program (MSSP), which…
AJMC reports that Humana has designed a new bundled payment model for maternity care. Initially, 5 practices will participate in a pilot study. While some claimed that bundled payment will improve quality and reduce cost (see “Bundle of Joy“), do we expect this to happen in practice? The key question is, what one means in…
That is the question that Carroll and co-authors try to answer in their latest NBER working paper (WP #23926). They examine the Arkansas Health Care Payment Improvement Initiative (APII), which is a state-wide, multi-payer episode-based program. Unlike most episode-based payment (EBP) models, provider participation in the program was mandatory (as of 2013). NBER summarizes the program…
The answer is maybe. Value-based insurance design ties patient cost sharing to the notion of a treatment’s value. Higher value treatments have lower cost sharing; lower value treatments have higher cost sharing. The Incidental Economist writes: In his own practice, Dr. Fendrick feels as if standard insurance is working against him and his patients. “They are deeply…
Value frameworks are all the rage of late. But are payers really using them? According to my colleague Jeremy Schafer, the answer is yes. From an article in Drug Topics: “Value assessment may become more important as the health-care market shifts to outcomes and value-based reimbursement models,” said Jeremy Schafer, PharmD, MBA, Senior Vice President…