GLOBE Model Finalized
The Centers for Medicare and Medicaid Services (CMS) finalized GLOBE, a mandatory five-year model linking Medicare Part B drug prices to cost benchmarks in 19 developed countries. The program starts in January and lasts for five years.
The model targets drugs in oncology, rheumatology, immunology, ophthalmology and endocrinology. The parallel Part D program is not yet finalized. The models build on various initiatives undertaken by the Trump administration.
Two problems here: GLOBE will reduce fee-for-service costs and effectively reduce Medicare Advantage payments without giving plans any lower costs. This could further reduce benefits in the program over time. As well, the final rule exempts from the model drug manufacturers in the parallel GENEROUS model for Medicaid. Drug makers struck price deals in Medicaid with the president. While I support Trump’s overall efforts, I think that is a mistake.
Additional articles: https://www.modernhealthcare.com/politics-regulation/mh-cms-globe-medicare-part-b-drug-model/ and https://www.beckershospitalreview.com/pharmacy/cms-finalizes-new-drug-pricing-model-7-notes/
#drugpricing #partb #partd #medicare
Site Neutral Payments Would Save
More mounting evidence of the need to implement site neutral. A recent Employee Benefit Research Institute analysis finds that healthcare spending could be reduced by $12.7 billion if medications administered in hospital outpatient departments were reimbursed at the same rates as those given at physician offices. The study found that allowed amounts were higher in hospital outpatient departments than in physicians’ offices for 93 physician-administered drugs. Per unit price differentials were a median 64% higher and 102% higher on average.
#drugpricing #siteneutral #hospitals
NSA Suits Demanding Payment Unsuccessful
Providers are suing health insurers for not paying No Surprises Act awards and most are unsuccessful. Courts in general have stated that they have no authority to enforce payment of those awards and the administration has done little to enforce as well.
#nsa #nosurprisesact #providers #healthplans
https://www.modernhealthcare.com/insurance/mh-no-surprises-act-lawsuits-idr-arbitration
New And Exiting MA Plans
The landscape files show that there will be four new entrants to the Medicare Advantage (MA) program in 2027, while 11 payers that sold individual MA plans in 2026 won’t offer them next year. Further the big MA plans are pulling out of hundreds of counties nationwide. Overall, Special Needs Plans will continue to grow.
Additional articles: https://www.beckerspayer.com/payer/medicare-advantage/10-payers-exiting-medicare-advantage-in-2027/ and https://www.beckerspayer.com/payer/medicare-advantage/4-new-medicare-advantage-insurers-in-2027/
#medicareadvantage #enrollment
— Marc S. Ryan
