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This Viewpoint discusses responses to the Change Healthcare cyberattack, concerns about consolidations and acquisitions of health care companies and organizations, and the need to clarify cybersecurity priorities.
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This Viewpoint discusses the provisions and potential of the new Centers for Medicare and Medicaid Services (CMS) Interoperability and Prior Authorization Final Rule.
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Autorização Prévia , Humanos , Estados Unidos , Interoperabilidade da Informação em Saúde , Reforma dos Serviços de Saúde/organização & administração , Registros Eletrônicos de SaúdeRESUMO
This Viewpoint discusses the current state of mental health parity reform, proposed amendments, and the challenges and considerations in play.
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Reforma dos Serviços de Saúde , Serviços de Saúde Mental , Humanos , Serviços de Saúde Mental/legislação & jurisprudência , Serviços de Saúde Mental/organização & administração , Reforma dos Serviços de Saúde/legislação & jurisprudência , Estados Unidos , Cobertura do Seguro/legislação & jurisprudênciaRESUMO
This Viewpoint presents the components of the payment model and the implementation challenges among the Center for Medicare and Medicaid Innovation, state Medicaid agencies, patients, and manufacturers.
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Terapia Baseada em Transplante de Células e Tecidos , Terapia Genética , Acessibilidade aos Serviços de Saúde , Medicaid , Humanos , Medicaid/legislação & jurisprudência , Estados UnidosRESUMO
This Viewpoint discusses the importance of the Drug Supply Chain Security Act and the need for pharmaceutical supply chain safeguards.
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Comércio , Preparações Farmacêuticas , Preparações Farmacêuticas/provisão & distribuição , Controle de Medicamentos e EntorpecentesRESUMO
This Viewpoint discusses alternative payments models and the responsibilities of health care professionals.
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This Viewpoint elucidates major components of the proposed rules about controlled substance prescribing in telehealth, highlights evolving considerations with the US Drug Enforcement Agency's approach, and offers potential improvements before finalization of the rules.
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Substâncias Controladas , Telemedicina , SulfadiazinaRESUMO
The Center for Medicare and Medicaid Innovation (CMMI) seeks to develop evidence-based alternative payment models (APM) to improve health care quality and reduce costs, but its performance in achieving these goals has been mixed. In October 2021, CMMI released its Innovation Strategy Refresh to highlight challenges faced by payment models and suggest new strategic approaches for the upcoming decade. While a welcome recast of organizational goals, the Refresh leaves space for how CMMI will address persistent issues. These include how CMMI can best engage physicians and patients in APMs, minimize conflicting incentives among APMs, reduce selection bias in model participation, and, ultimately, transition away from the fee-for-service framework that underlies much of Medicare reimbursement. This article provides guidance to CMMI's vision by examining challenges within CMMI's strategy for model building and offering solutions to mitigate these issues. These strategies include engaging beneficiaries in APM incentives, expanding operational flexibility to improve clinical behaviors (e.g., waivers), rectifying issues with conflicting model incentives, building voluntary short-term and mandatory long-term incentives to mitigate selection bias, and transitioning to an overriding population-based model to constrain net costs. Policy Points The Center for Medicare and Medicaid Innovation (CMMI) seeks to develop evidence-based alternative payment models (APM) to improve care quality and reduce health care cost, but its performance in achieving these goals has been mixed. In October 2021, CMMI released a "strategic refresh" of its goals but left space for how persistent issues to model development would be addressed. We propose strategies to engage physicians and patients in APMs, minimize conflicting incentives among APMs, reduce selection bias in model participation, and, ultimately, transition away from the fee-for-service framework that underlies much of Medicare reimbursement.
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Medicaid , Medicare , Idoso , Humanos , Estados Unidos , Mecanismo de Reembolso , Planos de Pagamento por Serviço Prestado , Qualidade da Assistência à SaúdeRESUMO
This article examines payer-provider partnerships in social determinants of health (SDoH) interventions, identifies important factors for an approach centered around return on investment (ROI) using integrated delivery and finance systems as case studies, and advocates for increased collaboration between payers and providers when addressing SDoH. Despite the numerous examples where payers and providers have attempted to independently address SDoH, there is limited evidence for the success of these interventions. Since most stakeholders individually do not have access to financial and clinical data, identifying an ROI for SDoH interventions is logistically challenging, but even when these data are available, stakeholders may not want to share their learnings due to negative findings and/or unwillingness to share proprietary information. These issues are further amplified by the effects of COVID-19 and its worsening effect on widening health disparities, but many payers and providers have risen to the challenge together. This article advocates for the importance of payer-provider partnerships to address SDoH and uses examples of integrated delivery and finance systems as case studies of how these partnerships could function. DISCLOSURES: No outside funding supported the writing of this article. Hartle is employed by Geisinger Health System. The other authors have nothing to disclose.
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Determinantes Sociais da Saúde/economia , COVID-19/economia , COVID-19/virologia , Humanos , Colaboração Intersetorial , SARS-CoV-2/patogenicidadeRESUMO
Value-based pharmaceutical contracts (VBPCs) are performance-based reimbursement agreements between healthcare payers and pharmaceutical manufacturers in which the price, amount, or nature of reimbursement is tied to value-based outcomes. VBPCs are often complex, and the nature of who benefits and in what ways can be unclear. We discuss how VBPCs compare with value-based payer-provider arrangements in terms of performance-based reimbursements and alignment of incentives. In addition, we examine how VBPCs can affect costs, clinical outcomes, and access to medications. Because these contracts are unlikely to reduce costs in isolation, we recommend taking a patient-centered approach when developing VBPCs and tying VBPCs to more overarching payer drug cost reduction strategies.
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Contratos/economia , Custos de Medicamentos , Indústria Farmacêutica/economia , Alocação de Recursos para a Atenção à Saúde/economia , Reembolso de Seguro de Saúde/economia , Seguro de Saúde Baseado em Valor/economia , Aquisição Baseada em Valor/economia , Redução de Custos , Análise Custo-Benefício , Gastos em Saúde , Acessibilidade aos Serviços de Saúde/economia , Humanos , Formulação de PolíticasRESUMO
Value-based pharmaceutical contracts (VBPCs) are performance-based reimbursement agreements between health care payers and pharmaceutical manufacturers in which the price, quantity, or nature of reimbursement is tied to value-based outcomes. As value-based payment models have permeated through much of the health care payment landscape via reimbursement to payers and providers, VBPCs offer opportunities for manufacturers to similarly engage in performance-based models. This article compares 2 VBPC schemes: "pay-for-failure" schemes, in which manufacturers offer rebates or discounts to payers for treatment failure, and "pay-for-success" schemes, in which manufacturers offer rebates or discounts to payers for treatment success. Each method has its own short-term and long-term trade-offs, and both lead to some degree of misaligned incentives between payers and manufacturers. These incentive differences have important downstream effects, influencing patient selection, provision of wraparound services, and nature of reimbursements. This analysis contrasts potential benefits and disadvantages for each of these approaches and offers potential solutions to address misalignment. For example, although pay-for-success models may be more aligned between payers and manufacturers, pay-for-failure contracts can be innovative and effective in controlling costs and/or improving outcomes. To illustrate, VBPCs aimed to reduce costs could incorporate total cost of care reduction as a value-based outcome. The authors encourage payers and manufacturers to consider a blended alternative where pay-for-failure and pay-for-success outcomes could be incorporated as VBPC outcomes. Since little is known about the effect of each scheme on outcomes, further research on VBPCs is necessary to fully understand how differing incentives ultimately affect clinical outcomes and costs. DISCLOSURES: No outside funding supported the writing of this article. Good and Kelly are employed by the UPMC Centers for Value-Based Pharmacy Initiatives and High-Value Health Care, and Parekh was employed by the UPMC Centers for Value-Based Pharmacy Initiatives and High-Value Health Care at the time of this study. The authors have no other disclosures to report.