Medicare: Value-Based Care, Pharmacy Benefit Managers, Trust Fund Reports and Fee-For-Service


Gustav A. Ravn (Editor)

Series: Health Care in Transition
BISAC: HEA028000

Table of Contents

Over the course of the last few years, our healthcare system has begun a shift toward rewarding physicians for the quality of care rather than the quantity, and building off these efforts, providers, doctors, health systems, and payers are willing to explore new value-based arrangements and open the door to providing new benefits for their beneficiaries. The Medicare Access and CHIP Reauthorization Act began to shift Medicare towards being a more value-based payment system. Chapter 1 discusses the models that are working toward improve the quality of care and reducing cost.

Total expenditures for the Medicare Part D drug program exceeded $100 billion in 2016. Part D plan sponsors may use a pharmacy benefit manager (PBM) to provide drug benefit management services for Part D coverage, such as negotiating drug rebates and other price concessions and paying pharmacy claims. Policymakers have sought a better understanding of PBMs’ roles in the drug supply chain and plans’ and PBMs’ efforts to manage Part D drug spending and use. Chapter 2 examines, (1) the extent to which Part D plan sponsors use PBMs, (2) trends in rebates and other price concessions obtained by both PBMs and plan sponsors for Part D drugs, and (3) how PBMs earn revenue for services provided to Part D plans.

The Social Security Act requires boards of trustees to issue reports to Congress by April 1 each year on the financial status of the Social Security and Medicare trust funds. Chapter 3 (1) describes how the boards of trustees develop the annual Trustees reports, and (2) examines the extent to which the boards of trustees have provided the reports to Congress by the April 1 deadline, and what factors account for any delays.

The Centers for Medicare & Medicaid Services (CMS) implemented a competitive bidding program (CBP) for certain durable medical equipment (DME), such as wheelchairs and oxygen. The Patient Protection and Affordable Care Act required CMS to adjust fee-for-service payment rates for certain DME items in non-bid areas. On January 1, 2016, adjusted rates for 393 items went into effect in non-bid areas. Chapter 4 examines (1) payment rate reductions and any changes in the number of suppliers; (2) any changes in the utilization of rate-adjusted items; and (3) available evidence related to potential changes in beneficiaries’ access to rate-adjusted items.
(Imprint: SNOVA)

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