Potential CMS changes to Medicare formulary design

Today at the Academy of Managed Care Pharmacy (AMCP) 2019 Annual Conference, I attended a session titled “Medicare Formulary Updates Impact. How will proposed recent rulemaking affect formulary design? Some answers are below. CMS 2020 draft call letter Improved access to opioid reversal agents. The CMS 2020 draft call letter would place opioid reversal agents…

Which Medicare initiatives use quality measures?

In December, CMS listed its quality measures that it is considering for incorporation into some of their value-based payment programs and quality reporting programs. However, which Medicare quality reporting and payment initiatives use quality measures?  A full list is below. Ambulatory Surgical Center Quality Reporting Program (ASCQR) End-Stage Renal Disease Quality Incentive Program (ESRD QIP)…

VBID comes to Medicare Advantage

CMS announced last week that they are extending their value-based insurance design (VBID) program to more states and more patients.  I describe VBID and the proposed changes below. What is VBID? Value-Based Insurance Design (VBID) generally refers to health insurers’ efforts to structure enrollee cost sharing and other health plan design elements to encourage enrollees…

Core Quality Measures

One challenge providers have faced in the past is that quality measure reporting has been complex.  Medicare may ask for quality measures with one definition, commercial payers may define quality a second way, and Medicaid may ask for a third definition of quality.  Keeping track of these definitions and recording quality measures distracts providers from actually providing quality…

What is Comprehensive Care for Joint Replacement?

Bundled Payments for Care Improvement (BPCI)A helpful post from Steven A. Farmer, Meaghan George and Mark B. McClellan explains.  Comprehensive Care for Joint Replacement (CCJR) is a bundled payment structure for hip and knee replacements.  CMS notes that: 2013, there were more than 400,000 inpatient primary procedures in Medicare, costing more than $7 billion for hospitalization alone.…

Too much competition?

Rarely due consumers think that too much competition is a problem.  According to the Centers for Medicare and Medicaid Services (CMS), however, this is a major issue for consumers when they choose Part D prescription drug health plans.  Avalere reports that: Proposed revisions to the meaningful differences policy will restrict the market’s top sponsors from…

Medicare reducing reimbursement for low-quality docs

In 2015, Medicare will begin implementing a value-based purchasing (VPB) program for physicians.  Initially the program will target only certain physicians and groups of physicians, but by 2017 all physicians is participate in this program. The VBP program will evaluate physicians along two broad dimensions: quality and cost.  In the final rule: Section 1848(p) of…