Reimbursement

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Class action book and gavel | Image credit: Zerbor – stock.adobe.com
GoodRx, PBMs Hit by Price Fixing Lawsuits

November 5th 2024

Independent pharmacies have filed 3 class action lawsuits against GoodRx Holdings and major pharmacy benefit managers (PBMs).

Screenshot of an interview with Stuart Staggs
The Challenge of Addressing Drug Spend to Drive Down Total Cost of Care in EOM

October 27th 2024

Stethoscope on money | Image credit: utah51 - adobe.stock.com
Pressure on Congress to Reform Medicare Physician Fee Schedule, Prevent Reimbursement Cuts

October 17th 2024

MinnOncology logo | Image: Minnesota Oncology
The Daily Balancing Act of Value-Based Cancer Care

October 14th 2024

Doing Things Differently: Wilfong Moves to Thyme Care
Doing Things Differently: Wilfong Moves to Thyme Care

October 12th 2024

More News

Al Benson, MD
March 22nd 2024

Dr Al Benson on Reimbursement for Supportive Care When Treating Patients With Cancer

Hayden E. Klein Rose McNulty
Al Benson, MD, FACP, FACCC, FASCO, medical oncologist at Northwestern University Feinberg School of Medicine and associate director of the Robert E. Tillery Comprehensive Cancer Center, discussed findings from a national survey assessing barriers to comprehensive cancer care delivery.
AMA President Blasts Payers’ Response to Cyberattack
March 14th 2024

AMA President Blasts Payers’ Response to Cyberattack

Mary Caffrey
As pressure from the Biden administration on UnitedHealth Group increases, physicians' groups weigh in following the unprecedented hack on Change Healthcare.
Pharmacist with patient | Image Credit: © Clayton D/peopleimages.com - stock.adobe.com
March 13th 2024

Fragmented Payer System, Vulnerable Supply Chain Among Threats to Accessing Essential Medicines

Christina Mattina
During a session of the 2024 V-BID Summit, panelists Stacie Dusetzina, PhD, and Inma Hernandez, PharmD, PhD, discussed how access to essential medications is curtailed not just by the longstanding complexities of insurance design but also by emerging threats such as supply chain weaknesses and cyberattacks.
What We're Reading
March 13th 2024

What We’re Reading: 340B Contract Pharmacies; Nursing Home Ownership; Health Items in Proposed Budget

AJMC Staff
An appeals court rules against the Pharmaceutical Research and Manufacturers of America in a 340B contract pharmacy dispute; for-profit investors’ acquisition of nursing homes has raised concerns about the quality of care provided in these facilities; President Joe Biden’s proposed budget for 2025 includes changes that would do away with the current system of biosimilar interchangeability.
Where Have All the Doctors Gone? Medicare Physician Payment Cuts Threaten Patient Access to Quality Care
March 12th 2024

Where Have All the Doctors Gone? Medicare Physician Payment Cuts Threaten Patient Access to Quality Care

Terry Wilcox
The author calls on Congress to address reimbursement shortfalls that are contributing to a growing physician shortage, with rural areas the hardest hit.
Biden Calls for Expanding Efforts to Control Drug Prices
March 8th 2024

Biden Calls for Expanding Efforts to Control Drug Prices

Mary Caffrey
In his State of the Union Address, the president called for expanding the number of drugs subject to Medicare price negotiations and extending a $2000 out-of-pocket cap beyond seniors.
AJMC
March 6th 2024

Increased Medicare Payments for Homeless Patients Provide New Opportunities for Care

Jack Tsai, PhD, MSCP
A new federal rule will provide higher Medicare payments for homeless patients, which may encourage hospitals to identify these patients and help them with their needs.
What We’re Reading: Case for Cost Free Preventative Services; Medicare Pay Bump; MA Home Health Care Disparities
March 4th 2024

What We’re Reading: Case for Cost-Free Preventive Services; Medicare Pay Bump; MA Home Health Care Disparities

AJMC Staff
Appeals court to review ruling wiping out some cost-free preventative services; a new legislation aims to boost reimbursement rates for medical providers; changes to coverage may limit elderly home care access
COA logo | Image credit: COA
February 27th 2024

COA Asks CMS to Resolve Express Scripts’ “Underwater” Payments Following End of DIR Fees

AJMC Staff
The Community Oncology Alliance (COA), which represents independent cancer care practices, has asked CMS to act following a dramatic drop in reimbursements from Express Scripts, Inc. effective January 1, 2024.
Business strategy | Image credit: WrightStudio - stock.adobe.com
February 23rd 2024

Kathy Oubre on Strategies to Mitigate Challenges When Adopting New Payment Models

Pearl Steinzor Rose McNulty
While adopting new payment models can come with challenges, there are strategies that can help oncology practices optimize their approaches, said Kathy Oubre, MS, CEO of Pontchartrain Cancer Center.
AJMC EBO logo | Image credit : AJMC
February 16th 2024

Rule Change for Patient Navigation Billing Is a Boon to Oncology Care, Practice Leaders Say

Julia Bonavitacola
Edward R. Arrowsmith, MD, MPH: Trust and Compromise Are Essential in Building Oncology Clinical Care Pathways
February 14th 2024

Edward R. Arrowsmith, MD, MPH: Trust and Compromise Are Essential in Building Oncology Clinical Care Pathways

Hayden E. Klein
From an interview conducted during Patient-Centered Oncology Care 2023.
Technology Helps Community Oncology Practices Implement PCM, CCM
February 14th 2024

Technology Helps Community Oncology Practices Implement PCM, CCM

Cameron Santoro
David A. Eagle, MD
February 12th 2024

Dr David Eagle: CMS Reimbursement Cuts Encourage Trend of Independent Physician Exodus

Giuliana Grossi
Over the past 20 years, Medicare physician pay has plummeted by 26% when adjusted for inflation, while hospital reimbursement has surged by 70%, prompting over 100,000 doctors to abandon independent practice for hospital or corporate employment since 2019.
Dr Lucy Langer
February 1st 2024

How UnitedHealthcare Incorporates Real-World Evidence Into Cancer Care Decision-Making, Policy Formulation

Hayden E. Klein
UnitedHealthcare is incorporating real-world evidence into pathways design and policy formulation, leveraging its members' data to evaluate the impact of different regimens on health resource utilization and costs, explains Lucy Langer, MD, MSHS, national medical director of oncology and genomics at UnitedHealthcare.
Kidney Care Partners logo | Image: LinkedIn
January 23rd 2024

Medicare Payment Rule Threatens Access to Life-Sustaining Kidney Care

John P. Butler Jennifer Payton, MHCA, BSN, RN, CNN
The authors call on Congress to reform Medicare reimbursement for dialysis, saying the recent rule puts clinics at risk of closure.
Christina Downey, MD | Image credit: American College of Rheumatology
January 8th 2024

To Preserve Access to Care, Congress Must Repair Medicare’s Broken Payment System

Christina Downey, MD
The author, chair of the Government Affairs Committee with the American College of Rheumatology, calls for support for efforts in Congress to reform the Physician Fee Schedule.
The Top 5 Reimbursement Content of 2023
December 31st 2023

Top 5 Most Popular Reimbursement Content of 2023

Laura Joszt, MA
The most popular reimbursement content of 2023 included coverage of the shift from the Oncology Care Model to the Enhancing Oncology Model, reactions to the 2024 Medicare Physician Fee Schedule, and concerns around denial of services in Medicare Advantage plans.
Lalan Wilfong, MD, in an interview on blue AJMC background
December 28th 2023

Dr Lalan Wilfong Highlights the Challenges of EOM Compared With OCM

Maggie L. Shaw Laura Joszt, MA
While the Enhancing Oncology Model is the successor of the Oncology Care Model, it includes some very real challenges for participating practices, explained Lalan Wilfong, MD, senior vice president of payer and care transformation at The US Oncology Network.
Top 5 AJAC 2023
December 26th 2023

Top 5 Most-Read AJAC Articles of 2023

Christina Mattina
In 2023, the most-read articles published in The American Journal of Accountable Care® (AJAC) highlighted innovative care models, lessons learned from health system partnerships, and much more.
What’s the Early View of the EOM? Partners Offer Their Takes
December 23rd 2023

What’s the Early View of the EOM? Partners Offer Their Takes

Maggie L. Shaw Mary Caffrey
Top 5 AJMC Journal Articles of 2023
December 21st 2023

Top 5 Most-Read AJMC® Journal Articles of 2023

Christina Mattina
In 2023, the most-read articles published in the peer-reviewed The American Journal of Managed Care® (AJMC®) explored predictive models, opioid prescribing, and much more.
Implementing ePROs Is the Lift Worth Taking, Basch Says
December 21st 2023

Implementing ePROs Is the Lift Worth Taking, Basch Says

Mary Caffrey
Coverage from The US Oncology Network Payer Transformation Summit, held September 27-29, 2023, in Atlanta, Georgia.
Miriam Atkins, MD, president of Community Oncology Alliance, during a video interview on blue AJMC background
December 21st 2023

COA’s Dr Miriam Atkins: APMs Can’t Be One Size Fits All

Maggie L. Shaw Laura Joszt, MA
A one-size-fits-all approach to alternative payment models (APMs) often isn’t very fair to community practices, said Miriam Atkins, MD, FACP, president of the Community Oncology Alliance.
AJMC SAP seal
December 21st 2023

Paying for Cancer Care Differently: A Look Into the Future

Mary Caffrey
Coverage from The US Oncology Network Payer Transformation Summit, held September 27-29, 2023, in Atlanta, Georgia.
What We’re Reading: CMS Launches Maternal Health Model; Respiratory Disease Vaccines Initiative; Anti-Abortion Groups Move to Thwart Abortion Ballot Measures
December 18th 2023

What We’re Reading: CMS' Maternal Health Model; Respiratory Disease Vaccines Initiative; Attempts to Thwart Abortion Ballot Measures

AJMC Staff
Initiative aims to enhance maternal health and birth outcomes; Wegovy success will help fund a vaccines initiative for respiratory diseases; new tactics aim to remove abortion from the 2024 ballot
Highlights From NAMCP Spring Managed Care Forum 2023
December 16th 2023

ICYMI: Highlights From the NAMCP Spring Forum 2023

Laura Joszt, MA
Top coverage from the National Association of Managed Care Physicians (NAMCP) Spring Managed Care Forum 2023 included sessions on value-based care implementation and best treatment practices.
Stethoscope with health icons next to a white piggy bank | Image credit: Kiattisak - stock.adobe.com
December 15th 2023

Senate Introduces Bill to Extend 5% Incentives for APMs

Todd Shryock
The bipartisan bill would help lower Medicare costs and improve quality of care, according to the National Association of ACOs.
Ted Okon, MBA, of Community Oncology Alliance, during a Zoom video interview
December 7th 2023

Ted Okon: Pressure Is Mounting on PBMs

Maggie L. Shaw Laura Joszt, MA
Activity to regulate pharmacy benefit managers (PBMs) has started in the states and is trickling up to the federal level, said Ted Okon, MBA, executive director of the Community Oncology Alliance.
Pharmacist getting medication | Image credit: Karanov images - stock.adobe.com
December 5th 2023

CVS Announces More Transparent Model for Pharmacy Reimbursement, Drug Costs

Laura Joszt, MA
The company is changing the way it prices prescription drugs and providing more transparency, which has been one focus of pharmacy benefit manager regulation efforts.
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