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Legislators and Legislation
Published in Mickey C. Smith, E.M. (Mick) Kolassa, Walter Steven Pray, Government, Big Pharma, and the People, 2020
Mickey C. Smith, E.M. (Mick) Kolassa, Walter Steven Pray
Finally in 2003, President Bush signed the Medicare Prescription Drug Improvement, and Modernization Act (MMA). Unlike the Medicare Catastrophic Coverage Act of 1988 and the Health Security Plan of 1993, there was virtually no strong political opposition to the MMA, except initially from the AARP. This new Medicare Part D would be financed in the same manner as Part B, namely, with 75% of its financing coming from the federal general tax fund and 25% from premiums paid by senior citizens. As mentioned earlier in this chapter, seniors were unhappy with what they perceived to be the lack of generosity in the benefit structure of the MMA but were reassured when the AARP vowed to fight for more generous benefits in the future. The pharmaceutical industry continued to voice its fears about eventual Price controls in the Medicare Program. Their fears were justified.
An Experiment in Challenging the Status Quo
Published in Ruchin Kansal, Jeff Huth, Redefining Innovation, 2018
As we have noted, the pace of change in the healthcare environment and its impact on the biopharmaceutical industry has been intensifying and accelerating for some time. The Patient Protection and Affordable Care Act (PPACA) or Obamacare, enacted in March 2010 and effective January 2011, was just one more catalyst. As a positive, the industry eventually benefited from an increase in covered patient populations although mainly in the least profitable Medicaid segment impacted by best-price requirements. On the other hand, the immediate impact, i.e., new taxes on the industry and further responsibility to cover patients’ Medicare Part D covered drug costs (self-administered prescription drugs, as opposed to Medicare Part B covered drugs that are administered by physicians in a clinical setting) while they experienced the “donut hole” coverage gap, was mostly viewed as detrimental to the industry. This regulation was such a dramatic event that virtually every biopharma company and many players across the healthcare ecosystem were forced to examine some of their business fundamentals.
Further discussion of our Medicare and Medicaid proposals
Published in Phelps Charles E, Parente Stephen T, The Economics of US Health Care Policy, 2017
Phelps Charles E, Parente Stephen T
We have good legislative precedent in the Medicare Part D plans that are allowed to specify not only their own formulary (the drugs they will cover) but also the pricing attached to each drug (typically ranging from a small copay for 30 or 90 days of a generic drug in Tier 1 to much higher copays for expensive and rarely used drugs in Tier 4). We simply propose to let MA plans have the same freedom in determining the coverages they offer. Competition between plans (where consumers trade off costs and coverage) will illuminate how consumer preferences sort out.
Antipsychotic utilization, healthcare resource use and costs, and quality of care among fee-for-service Medicare beneficiaries with schizophrenia in the United States
Published in Journal of Medical Economics, 2023
Pengxiang Li, Carmela Benson, Zhi Geng, Sanghyuk Seo, Charmi Patel, Jalpa A. Doshi
HRU measures included the proportion of all beneficiaries with schizophrenia in 2019 with any inpatient admission, any emergency room (ER) visit, and any evaluation and management (E&M) physician visit. We also assessed the mean number of admissions/visits among those with evidence of at least one admission/visit in 2019. Similarly, the total length of stay among those with any inpatient admission in 2019 was also examined. Healthcare cost measures included total healthcare costs, medical costs and pharmacy costs. Medical costs were retrieved from the Medicare Part A and B medical claims including the inpatient, hospital outpatient, and carrier claims files in 2019. The HRU and cost measures were categorized as all-cause, mental health-related, and schizophrenia-related. Mental health-related HRU and medical cost measures were defined based on claims with an ICD-10 diagnosis code between F00 and F99 (inclusive) in any diagnosis position. Schizophrenia-related HRU and medical cost measures were defined based on claims with an ICD-10 diagnosis code of F20.XX, F21, and F25.X in any diagnosis position. Pharmacy costs were based on Medicare Part D prescription drug claims. All-cause pharmacy costs included costs for all prescription drug claims during 2019. Mental health-related pharmacy costs were defined as costs for claims with National Drug Codes (NDCs) for mood stabilizers, anxiolytics, antidepressants, and antipsychotics. Schizophrenia-related pharmacy costs were defined as costs for antipsychotics.
The Prevalence of Diagnosis of Major Eye Diseases and their Associated Payments in the Medicare Fee-for-Service Program
Published in Ophthalmic Epidemiology, 2023
John S. Wittenborn, Qian Gu, Erkan Erdem, Farah Ahmed, Ping Zhang, Jinan Saaddine, Elizabeth A. Lundeen, David B. Rein
We analyzed 2018 100% Medicare FFS Part B claims and Part D prescription drug events (PDE) data using the Centers for Medicare & Medicaid Services (CMS) Virtual Research Data Center (VRDC), and the Master Beneficiary Summary File (MBSF) Base File. We restricted the initial sample to Medicare Part B beneficiaries appearing in the claims database who were continuously enrolled for all 12 months of 2018. Medicare Part B covers outpatient services such as eye exams and treatments for eye conditions, including physician services provided in hospitals, physician administered drugs such as intravitreal injections, medical and laboratory services and durable medical equipment. Medicare Part D covers approved prescription drugs including glaucoma medications. Not all Part B beneficiaries are enrolled in Part D. We did not include Part A (inpatient services) because ophthalmology services are generally covered as outpatient services under Part B, even when provided in hospitals, and previous studies have shown that inpatient costs related to a diagnosis code for the four conditions listed are minimal.10 We did not include Part C, which consists of MA plans, due to lack of access to representative claims data. Of note, Medicare FFS does not reimburse for vision care, such as glasses or contact lenses, or for routine eye exams unless the beneficiary has a diagnosed eye disease.
Psoriasis drugs in the medicare population: dermatologists’ spending and prescription patterns
Published in Journal of Dermatological Treatment, 2022
Jason J. Yang, Alexander T. Pham, Nolan J. Maloney, Omar Aly, Kyle Cheng
The price of biologic medications places financial burden on the healthcare system as well as on patients, which affects accessibility as well as adherence (5,6). Despite the closure of the coverage gap in Medicare part D—meant to reduce out-of-pocket costs—patients may still experience similar financial burden in the setting of increasing drug prices, as there remains no out-of-pocket maximum even after entering the catastrophic coverage phase (7). As our understanding of psoriasis pathogenesis and development of biologic therapies progresses, the usage of these new expensive agents that are also effective in treating psoriatic arthritis appears to be increasing (8,9). An interdisciplinary approach to health care that includes physicians, pharmacists, nurses, and other health care professionals will improve the quality of patient care (10). In this study, we aimed to explore prescription patterns for recently approved medications for psoriasis and to assess spending in Medicare Part D related to these prescriptions by dermatologists.