Could Formularies Be Coming to Medicare Part B?


Formulary management may one day come to Medicare Part B, predicts industry insider Dan Mendelson. The founder/president of healthcare consulting firm Avalere Health and a former Clinton administration official made the statement September 28 at the National Association of Specialty Pharmacies conference, according a report by Inside CMS. Mendelson predicted Congress would let private plans manage drugs in Medicare Part B using formularies and other tools currently in place for Part D. Congress could decide to keep Part B and Part D separate, or integrate Part B drug coverage into Part D. “If you think about all the drugs purchased under Medicare Part B, it’s a large market,” said Mendelson, according to Inside CMS. “Right now, there’s really no formulary, there’s no cost control, there’s no cost constraints, no exclusionary opportunities. … At what point does the government figure out that that’s something that might be a way to manage those costs?” Mendelson referenced a poll in which Republican voters overwhelmingly cited drug prices as their greatest healthcare concern, and noted that government programs offer private plans opportunities for new growth—though with this growth comes an expectation that quality metrics will be met.


CMS Earmarks $347 Million to Reduce Readmissions, Hospital-Acquired Conditions

On September 29, the Centers for Medicare & Medicaid Services (CMS) announced that it had awarded $347 million to different organizations as part of its continued efforts to reduce hospital-acquired conditions and readmissions in the Medicare program. Funds for the Hospital Improvement and Innovation Network will be paid through contracts to 16 hospital associations, quality-improvement organizations, and health-system organizations. Built in to these contracts will be a set of ambitious goals to improve patient safety, including a 20% reduction in overall patient harm and a 12% decrease in 30-day hospital readmissions by 2019, from the 2014 baseline. “We have made significant progress in keeping patients safe—an estimated 2.1 million fewer patients harmed, 87,000 lives saved, and nearly $20 billion in cost-savings from 2010 to 2014,” noted Patrick Conway, CMS acting principal deputy administrator and chief medical officer. “And we are focused on accelerating improvement efforts.” Included in the targeted hospital-acquired conditions are adverse drug events, pressure ulcers, sepsis, surgical-site infections, and venous thromboembolism, among others. In addition to reducing the numbers themselves, network organizations will help identify solutions to share with other providers.


Cheaper Premiums for Medicare Advantage, as Enrollment Continues to Rise


On September 22, CMS announced an approximately 4% decrease in Medicare Advantage monthly premiums for 2017, from $32.59 on average to $31.40. This represents a 13% decrease overall since passage of the Affordable Care Act. Enrollment, meanwhile is expected to continue its climb, with a projected 18.5 million enrollees for 2017—a remarkable 60% jump over 2010 enrollment. In addition, CMS reported, average Medicare Part D premiums will also remain stable for 2017. “Medicare Advantage and the prescription drug benefit continue to be a great option for seniors and people living with disabilities,” said Andy Slavitt, CMS acting administrator. “Medicare enrollees will continue to have access to predictable premiums and high quality care.” Beyond lower premiums, beneficiaries can expect more supplemental benefits from Medicare Advantage plans in 2017, including dental, vision, and hearing benefits.


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