Changes to pricing & reimbursement
Because of legal challenges to the policies of the centres for Medicare and Medicaid Services (CMS), it appears that any drug pricing reform will have to go through Congress. Currently, legislators are debating reforms such as rebate safe harbour removal, international reference pricing, and drug re importation, as well as redesigns to Medicare benefits. All of these changes may shift the pricing and reimbursement responsibility from CMS to drug manufacturers and payers. This may improve the financial picture for Medicare but may also add billions of dollars in costs.
Adjuster programs
Drug manufacturers often have programs to help patients by reducing their Koh-pay. Because of this, however, big pharmaceutical benefit managers have instituted Koh-pay adjuster programs, which are designed to move more of the cost to the manufacturer.
These programs prevent patient Koh-pays from counting toward deductibles or out-of-pocket caps. With these programs, patients are not getting the help with the Koh-pays they expect, causing them to discontinue treatment, which can lead to greater health
340B drug discount programs
Drug manufacturers are required to participate in this program if they are also participating in Medicare. The 340B program has grown a great deal and now accounts for about 13 percent of all US pharmaceutical sales.
But the program presents challenges for manufacturers. The discount is given upfront, so manufacturers often have to pay an access rebate in addition to the discounted price, which can affect margins and revenue.
Purchasing power
The purchasing power of payers like PBMS is growing, and this is leading to higher costs for patients who use specialty medications.
Value-based pricing
New drugs are often high-priced, and this creates a problem of how these drugs will be paid for. Value-based pricing is seen as one solution to the problem to ensure that lower-income patients have access to high-cost drugs.
Patient experiences
Another trend is the redesign of patient support programs by drug manufacturers to account for many of the social, economic, and cultural factors that affect patients’ health, as well as reaching out to more vulnerable populations.
Changes to Medicare
The federal government has recently proposed changes to Medicare pricing and reimbursement. These changes will probably shift more responsibility from patients and CMS to manufacturers and payers. This will also necessitate market adjustments to cope with these changes.
For example, payers may look to streamline formularies to a greater extent. There may also be new out-of-pocket spending caps, which will make it easier for patients to stay on more expensive treatment throughout the entire year.
New frameworks for delivering care
Patient care is now being delivered in places other than just hospitals and doctor’s offices. Places like Walmart, CVS, and Walgreen are doing more patient care and community health.
Also, health-care organizations at various care delivery stages are creating alliances to make their care more effective. This allows for a greater number of services to patients and increases access to care as well as lowers costs. But it also has its risks, like any other business venture.
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