2022 Health Policy and Social Determinants of Health Affecting Quality, Cost, and Access
Fall is here! Hopefully you are enjoying some cooler weather wherever you are! I am Cynthia Miller, MD, MPH, FACP, Vice President – Access Experience Team, your new editor of The All Access Newsletter. Trained as an internist with a Master’s in Public Health, I have over 15 years of experience in the medical field. For the first decade, I practiced primary care and then spent 5 years in the pharmacy payer space. I look forward to bringing your attention to the expertise Precision’s Access Experience Team has around policy, healthcare trends, payer insights, social determinants of health, and many other topics.
This summer has been a busy time for CMMI, Congress and the Courts. From changes in 340B regulation, to the revamped Enhanced Oncology Care Model, breakthrough initiatives in social determinants of health, and the recently approved Inflation Reduction Act, healthcare has entered a novel era that impacts all stakeholders, including patients, individual physicians, health systems, and pharmaceutical companies.
In this edition of the All Access Newsletter, we have asked our key expert ex-payers to provide insights into the trends and developments they foresee impacting healthcare and therapy access in 2022 and their potential impact.
340B: Implications of the New Ruling
Dominic Galante, Chief Medical Officer – Access Experience Team
340B reimbursements have been rising in the last several years and have come under increased scrutiny. Dominic Galante will lead us through the recent complex legal battle over 340B reimbursements.
The Next Steps in the Oncology Care Model (OCM) – Potential Implications and Opportunities
Janet Serluco, MS – VP – Access Experience Team, Oncology Lead
CMMI finally revealed the long-awaited continuation of the Oncology Care Model! Janet Serluco discusses the changes in the Enhanced Oncology Model and how she predicts physicians and payers will respond. She wraps up her article with suggestions for how pharmaceutical companies can respond and determine the impact on their business.
Climate, Taxes, and Price Controls – What’s In the Inflation Reduction Act
Ryan Cox, VP, Director – Access Experience Team
Congress finally passed the Inflation Reduction act this Summer after much debate. Ryan Cox distills the Act into some of the most salient points and discusses the wide-ranging affects it will have payers, pharmaceutical companies, and the future of healthcare. While the implications of this legislation are still being discussed, Ryan gives us a first glance into what to expect.
Ramping Up SDOH Quality Measures within Value-Based Reimbursement Roadmaps
Maureen Hennessey, SVP, Director of Value Transformation and Cynthia Miller, VP Director – Access Experience Team
Several national organizations, including CMS and NCQA, are recognizing the effect of social determinants of health and health equity on patient outcomes. Recently, they have launched several initiatives to measure the effect of SDOH and equity on quality as well as promoting interventions on the part of physicians and payers. Maureen and I suggest several tools pharmaceutical companies can use to become partners in advancing health equity.
We believe you will find these discussions about new policies and their impact on access insightful as you navigate the payer landscape. As always, please feel free to drop me a note and let me know if you have a topic suggestion for the payer team to address, and we’ll do our best to cover it in a future edition.
MD, MPH, FACP
VP, Medical Director
Access Experience Team
All Access is a bimonthly newsletter featuring key insights from our team of former payers intended specifically for market access leaders. It is published by PRECISIONvalue.
On June 15, 2022, the Supreme Court of the United States (SCOTUS) ruled in favor of hospitals over Medicare regarding a 340B reimbursement policy instituted in 2018 and unanimously decided that the almost 30% in cuts to Medicare outpatient drug payments for hospitals participating in the 340B drug pricing program was unlawful.
The OCM was a 5-year voluntary advanced payment model that the Centers for Medicare and Medicaid Services (CMS) developed through the Innovation Center (CMMI) beginning July 1, 2016. CMS changes to advanced payment models due to the COVID-19 Public Health Emergency turned it into a 6-year model, which ended June 30, 2022.
President Biden signed the Inflation Reduction Act (IRA) into law on August 16th. The law includes new spending on climate initiatives, new taxes and enforcement, and drug pricing controls include significant changes to the Medicare Part D benefit. On the surface, measures to address drug pricing has had broad bipartisan support; however, the implications from this law may have unintended consequences to the Part D beneficiaries, payers, as well as to drug development and innovation for years.
The Centers for Medicare & Medicaid Services (CMS) recognize that health care spending rises as a percent of gross domestic product (GDP) yearly while also underperforming on quality and equity. In this article we will review current and emerging initiatives including new and proposed SDOH quality measures and activities linked to plan and provider payments and incentives, discuss barriers to success, and propose win-win solutions for pharmaceutical companies to advance these initiatives.