4. International reference pricing for therapies paid for by Medicare
Both political parties have proposed plans that involve some form of reference pricing, and a recently released study by the Senate Ways and Means Committee found some therapies may cost fourfold more in the United States than other comparator countries.
Meg Alexander, managing director, reputation and risk management practice for Syneos Health, a healthcare research organization based in Morrisville, North Carolina, says some reference pricing proposals, such as the version posed by the administration, may enable payers to more closely “manage” certain drug categories. However, reference pricing could also deliver several un-intended consequences that may have the opposite effect of making drugs affordable and accessible for Americans.
“For example, some reference pricing proposals involve vendor ‘middle men’ for drug management, increased payer management strategies, and could involve a flat physician administration fee for therapies offered under Medicare Part B,” she says. “This may translate into fewer physicians offering such therapies due to administrative and reimbursement hassles; thereby leading to American patients potentially struggling to find doctors to administer the medicines they need.”
5. ETC model
Bryan Becker, MD, chief medical officer for DaVita Integrated Kidney Care, a Fortune 500 healthcare provider based in Denver, Colorado, says following an executive order signed in July— Advancing American Kidney Health—the Center for Medicare and Medicaid Innovation (CMMI) announced voluntary and mandatory payment models, though the details of the voluntary models, which have some general features that mirror the primary care payment models, have not been released yet.
“The mandatory model, otherwise known as the ESRD Treatment Choice [ETC] model, would take effect in 2020,” he says. “The ETC as proposed extends to half of the Hospital Referral Regions [HRRs] in the country and includes the patients in the dialysis clinics in those HRRs and the nephrologists who work with patients in those clinics.”
The claims from both nephrologists and clinics will be adjusted based on home and transplant rates for chronic kidney disease stage 4/5 or ESRD Medicare FFS patients in areas identified by CMS as an ETC region.