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2.
Am J Law Med ; 45(2-3): 106-129, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31722633

RESUMO

Beginning on inauguration day, President Trump has attempted an executive repeal of the Affordable Care Act. In doing so, he has tested the limits of presidential power. He has challenged the force of institutional and non-institutional constraints. And, ironically, he has helped boost public support for the ACA's central features. The first two sections of this article respectively consider the use of the President's tools to advance and to subvert health reform. The final two sections consider the forces constraining the administration's attempted executive repeal. I argue that the most important institutional constraint, thus far, is found in multifaceted actions by states - and not only blue states. I also highlight the force of public voices. Personal stories, public opinion, and 2018 election results - bolstered by presidential messaging - reflect growing support for government-grounded options and statutory coverage protections. Indeed, in a polarized time, "refine and revise" seems poised to supplant "repeal and replace" as the conservative focus countering liberal pressure for a common option grounded in Medicare.


Assuntos
Pessoal Administrativo , Reforma dos Serviços de Saúde/legislação & jurisprudência , Patient Protection and Affordable Care Act/legislação & jurisprudência , Política , Governo Federal , Financiamento Governamental/legislação & jurisprudência , Financiamento Governamental/organização & administração , Regulamentação Governamental , Reforma dos Serviços de Saúde/história , História do Século XX , História do Século XXI , Humanos , Reembolso de Seguro de Saúde/legislação & jurisprudência , Jurisprudência , Medicaid/legislação & jurisprudência , Medicaid/organização & administração , Medicare/legislação & jurisprudência , Medicare/organização & administração , Patient Protection and Affordable Care Act/organização & administração , Cobertura de Condição Pré-Existente , Opinião Pública , Governo Estadual , Estados Unidos
6.
Issue Brief (Commonw Fund) ; 2019: 1-11, 2019 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-30990594

RESUMO

Issue: Pharmacy benefit managers (PBMs) are responsible for negotiating payment rates for a large share of prescription drugs distributed in the U.S. Recently, policymakers have expressed concern that certain PBMs' business practices may not be consistent with public policy goals to improve the value of pharmaceutical spending. Goal: We sought to explain key controversies related to PBM practices and their roles in driving value in the pharmaceutical market. Methods: Literature review and feedback from top experts on PBM business practices and potential policy solutions. Key Findings and Conclusion: In some cases, PBMs' use of rebates has contributed to high pharmaceutical costs, yet proposed solutions to the rebate controversy--including passing the rebate through to payers or patients--will not on their own reduce overall pharmaceutical spending without other policies that drive toward value. Policymakers seeking to reform pharmaceutical reimbursement beyond the practice of rebates will need to consider these changes in light of the recent mergers between PBMs and insurers and the entry of new market competitors.


Assuntos
Pessoal Administrativo/economia , Pessoal Administrativo/legislação & jurisprudência , Benefícios do Seguro/economia , Benefícios do Seguro/legislação & jurisprudência , Seguro de Serviços Farmacêuticos/economia , Seguro de Serviços Farmacêuticos/legislação & jurisprudência , Previsões , Formulários Farmacêuticos como Assunto , Setor de Assistência à Saúde/tendências , Humanos , Reembolso de Seguro de Saúde/economia , Reembolso de Seguro de Saúde/legislação & jurisprudência , Medicare Part D/economia , Medicare Part D/legislação & jurisprudência , Estados Unidos
9.
Tex Med ; 115(3): 20-25, 2019 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-30855697

RESUMO

Molina Healthcare of Texas isn't the only insurer to give physicians prompt-pay problems, and it won't be the last. Some of the practices trying to recover payments blame not just the health plan, but also the extended response time from the state regulator overseeing insurance products and conduct: the Texas Department of Insurance, which says it's hiring staff and making other changes to improve that response.


Assuntos
Sistemas Pré-Pagos de Saúde/legislação & jurisprudência , Revisão da Utilização de Seguros/legislação & jurisprudência , Reembolso de Seguro de Saúde/estatística & dados numéricos , Médicos/economia , Humanos , Reembolso de Seguro de Saúde/legislação & jurisprudência , Governo Estadual , Texas , Fatores de Tempo
15.
Seton Hall Law Rev ; 49(1): 1-51, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30557921

RESUMO

For the better part of a decade, Americans have had a front-row seat to a fervent and turbulent debate over the future of their health care system. The passage of the Patient Protection and Affordable Care Act of 2010 (ACA), the most comprehensive health reform effort since the mid-1960s, ushered in a new era in health law and policy, granting millions of Americans access to health care. After multiple legal challenges and congressional efforts that ultimately failed to slay the law, the ACA had become entrenched by the end of the Obama administration, even though pieces of the law had failed to work exactly as planned. Now, with the surprising election of President Donald Trump, reenergized Republicans are targeting the law once more, and it suddenly appears more vulnerable than ever. Dynamic uncertainty again permeates the national debate. Although most powerful protections of the ACA may evaporate--no small event, to be sure--the value-based era which it unleashed seems here to stay. Indeed, this era--focused on efficiency, standardization, and quality within American medicine--has just begun to bear fruit. Illustrated prominently by recent changes to Medicare that alter how the program pays its doctors for services they provide to its beneficiaries, America is moving away from the old strictures of fee-for-service medicine. At the same time, traditional legal tools, and particularly the federal government's most prominent anti-fraud tool, the civil federal False Claims Act (FCA), seem to be facing new limits. This has been recently evident in medical necessity-based fraud cases, and particularly highly publicized fights that have targeted the burgeoning industry of hospice care. This Article tracks this development, ultimately arguing that the move to "reimbursement-based regulation" may be a positive step in finally reining in the worst excesses of American health care. But it also cautions against the deceptive simplicity of allowing medical heterogeneity and clinical complexity to prevent application of America's most powerful anti-fraud tools to its medical industry. Just because reimbursement policy has shifted to shoulder some of the regulatory burden of overtreatment does not mean that health care fraud--like fee-for-service medicine--should be confined to the past. In the end--and regardless of whatever legislation the national debate surrounding American health care produces--American medicine must adequately address its susceptibility to overtreatment, its incentives toward financial excess and waste, and its inability to push providers and entities into adopting more efficient practices. Medicare is finally moving quickly to bring about effective changes, and the program is seeking clarity in the midst of a period of tremendous uncertainty for American health care.


Assuntos
Fraude/legislação & jurisprudência , Cuidados Paliativos na Terminalidade da Vida/legislação & jurisprudência , Medicare/legislação & jurisprudência , Cuidados Paliativos na Terminalidade da Vida/economia , Humanos , Revisão da Utilização de Seguros/legislação & jurisprudência , Reembolso de Seguro de Saúde/legislação & jurisprudência , Medicare/economia , Estados Unidos
20.
Fed Regist ; 83(108): 25947-9, 2018 Jun 05.
Artigo em Inglês | MEDLINE | ID: mdl-30019872

RESUMO

This document announces the addition of 31 Healthcare Common Procedure Coding System (HCPCS) codes to the Required Prior Authorization List of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items that require prior authorization as a condition of payment. Prior authorization for these codes will be implemented nationwide.


Assuntos
Equipamentos Médicos Duráveis/economia , Reembolso de Seguro de Saúde/economia , Reembolso de Seguro de Saúde/legislação & jurisprudência , Medicare/economia , Medicare/legislação & jurisprudência , Aparelhos Ortopédicos/economia , Próteses e Implantes/economia , Humanos , Benefícios do Seguro , Cobertura do Seguro , Estados Unidos
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