Medicare Compliance & Reimbursement

Health policy researchers Ruth Lopert, BMed, MMedSc, and Marilyn Moon, PhD, recommended in a Commonwealth Fund-supported study that outcome assessments of the Part D benefit should emphasize data on therapeutic value rather than drug pricing alone.

"A long-term objective should be integrating drug benefits with comprehensive health coverage," said researchers in the Dec. 3 Commonwealth Fund release. They advised that the Centers for Medicare and Medicaid Services (CMS) develop a comprehensive plan to compete with private plans.

A CMS plan would require a comprehensive but closed formulary, built on transparent, evidence-based assessments of comparative effectiveness and value for money, according to the researchers. As a result, there may be a limited number of generic or brand versions of drugs in the plan or the number of choices within a therapeutic class. Researchers further stressed that a CMS plan should abide by fixed cost-sharing arrangements and make beneficiaries aware of their fixed contributions.

Researchers also recommended introduction of a reference pricing form or price fixation of drugs at the same level. This would not only control prices, according to Lopert and Moon, but would also "establish a conceptual framework in which Medicare coverage supports the purchase of health 'outcomes' rather than the drugs."

In addition, researchers suggested that Medicare Parts A, B, and D be melded into an integrated benefit. "An integrated benefit with treatment options based on assessments of effectiveness and cost-effectiveness would ensure that early and judicious use of preventive drug therapies is encouraged by an understanding of downstream outcomes and cost offsets."