Unbiased Analysis of Today's Healthcare Issues
How does formulary restrictions impact health outcomes for patients with multiple sclerosis (MS)? To answer this question, Blaylock, Van Nuys and Joyce (2025) use data 100% Medicare claims data from 2018-2022 covering patients with both prescription drug plans (PDPs) and Medicare Advantage Prescription Drug plans (MA-PDs). Individuals were categorized as above vs. below average formulary…
There were lots of very interesting sessions at ISPOR 2025 in Montreal. One of my favorites that I was able to attend was titled “Medicare Price Negotiation of Part B Drugs: Implications for Provider Reimbursement and Commercial Spillover“. The session was moderated by Sean Sullivan of University of Washington, with Kristi Martin from the Centers…
The answer is ‘yes’ according to a paper by Borrelli et al. (2025). The authors use annual Medicare Star Rating health plan performance for Medicare Advantage-Part D (MAPD) plans over the past decade (2015 to 2024). They find that: For plans achieving at least 4 stars on the medication adherence measures, 70%-74% of them also…
Chuanzi Yue and Marisa Miraldo argue in a recent Health Affairs Forefront piece that the answer is ‘yes’, but I am highly skeptical of their claim. Will IRA cause firms to allocate funds from marketing to R&D? One point they make is that the IRA’s Medicare Drug Price Negotiation program will reduce pharmaceutical expenses on…
Medicare drug price negotiation is here. The maximum fair prices (MFP) set by Medicare lead to discounts between 38% and 79%. In fact, the real discounts are larger since the figures listed in the table below are discounts off of 2023 prices (rather than 2024 prices). How did the negotiation process work? CMS’s fact sheet…
Recently, the Inflation Reduction Act (IRA) is getting a lot of attention, particularly for its provision that allows CMS to start drug price negotiation for selected drugs 9 (small molecules) or 13 (biologics) years after drug launch. However, the Centers for Medicare and Medicaid Innovation (CMMI) has proposed a number of a number of payment…
Potentially so, argues Adam Fein of Drug Channels. There are two mechanisms for this. First, for drugs not covered in the maximum fair price negotiations, Fein argues that drugs with high list prices and large rebates would lead to more net savings compared to drugs with lower list price and rebates in part because in…
The Kaiser Family Foundation (KFF) identifies the Part D drugs on which Medicare spends the most money. This is an important question since CMS will begin drug price negotiation under the Inflation Reduction Act (IRA) based on the top 10 top spending Part D drugs. Some relevant statistics and figures are below. In 2021, Medicare…
ASPE has a report out on the potential impact of the Inflation Reduction Act on Medicare Part D beneficiary out-of-pocket spending. This is a particularly relevant topic as the share of patients who have fallen into the catastrophic coverage has increased over time. Some of the medical conditions with the top out-of-pocket payments for Medicare…
That is the summary takeaway I had form reviewing the 91 page CMS guidance on the Inflation Reduction Act (IRA) maximum fair price (MFP) negotiation released about 10 days ago. Below, I summarize some of the key findings. SELECTING DRUG FOR PRICE NEGOTIATION Unsurprisingly, CMS is looking for the highest cost drugs among the 10…