Medicare coverage and reimbursement of outpatient prescription drugs in the US: History, recent changes and outlook for the future

Applied Health Economics and Health Policy

Volumn 4, Issue 1, 2005, Pages 9-14

  Forrest, Sharon ^a   Goetghebeur, Mireille M ^a   Hay, Joel ^b  

^a INSTITUTE FOR RESEARCH IN IMMUNOLOGY AND CANCER   (Canada)

^b UNIVERSITY OF SOUTHERN CALIFORNIA   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

COMPETITION; COST EFFECTIVENESS ANALYSIS; DISABILITY; DRUG COST; DRUG INDUSTRY; ELDERLY CARE; HEALTH CARE COST; HEALTH CARE PERSONNEL; HEALTH INSURANCE; HEALTH PROGRAM; HUMAN; LAW; MEDICAL PRACTICE; MEDICARE; OUTPATIENT; PATIENT CARE; PHARMACY; PHYSICIAN; PRESCRIPTION; REVIEW; UNITED STATES; AMBULATORY CARE; ARTICLE; ORGANIZATION; ORGANIZATION AND MANAGEMENT; REIMBURSEMENT;

AMBULATORY CARE; HUMANS; INSURANCE, PHARMACEUTICAL SERVICES; MEDICARE PART B; ORGANIZATIONAL INNOVATION; REIMBURSEMENT MECHANISMS; UNITED STATES;

EID: 25144518125     PISSN: 11755652     EISSN: None     Source Type: Journal    
DOI: 10.2165/00148365-200504010-00003     Document Type: Review

References (35)

1. Centers for Medicare and Medicaid Services. Medicare enrollment: all beneficiaries as of July 2001 [online]. Available from URL: http://www.cms.gov/ statistics/enrollment/st01all.asp [Accessed 2003 Feb 6]
2. Medicare Payment Advisory Commission. Report to the Congress: variation and innovation in medicine [online]. Available from URL: http://www.medpac.gov/ publications/congressional_reports/June03_Entire_Report.pdf [Accessed 2004 Jun 1]
3. O'Sullivan J. Medicare prescription drug coverage for beneficiaries: background and issues [report no. RL30819]. Washington, DC: Congressional Research Service, The Library of Congress, 2001 Jun
4. O'Sullivan J. Medicare: payments for covered prescription drugs [report no. RL31419]. Washington, DC: Congressional Research Service, The Library of Congress, 2002 May
5. Association of Community Cancer Centers. OIG and GAO recommend reforming Medicare's drug reimbursement methodology [online]. Available from URL: http://www.accc-cancer.org/news/Medicarereform.asp [Accessed 2003 Jan 13]
6. Centers for Medicare and Medicaid Services. Testimony of Thomas A. Scully, Administrator Centers for Medicare and Medicaid Services on reimbursement and access to prescription drugs under Medicare Part B; Senate Finance Committee Subcommittee on Health [online]. Available from URL: http://cms.hhs.gov/media/press/testimony.asp?.Counter = 630 [Accessed 2003 Jan 8]
7. Assistant Secretary for Legislation. Testimony on Medicare coverage of self-administered drugs by Michael Hash [online]. Available from URL: http://www.hhs.gov/asl/testify/t000323a.html [Accessed 2003 Jan 7]
8. Georgia Medicare Part B. Georgia Medicare Part B's process for classifying drugs or biologicals as 'self administered' [online]. Available from URL: http://www.gamedicare.com/provider/SelfAdmin.htm [Accessed 2003 Jan 13]
9. Meyer BM, Cantwell KM. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003: implications for health-system pharmacy. Am J Health Syst Pharm 2004; 61 (10): 1042-51
10. Landon BE, Reschovsky JD, Blumenthal D. Physicians' views of formularies: implications for Medicare drug benefit design. Health Aff (Millwood) 2004; 23 (1): 218-26
11. Thompson Healthcare. Red Book® [online]. Available from URL: http://www.thomson.com/common/view_brand.jsp?section=healthcare& body_include=/healthcare/brand_overviews/MEDEC_DIR_Red_Book&page_mode= full&subsection=&secondary=&subnav=prodaz&tertiary= &product_name=RED_BOOK® [Accessed 2005 Jun 21]
12. First Databank. Blue Book AWP [online]. Available from URL: http://www.firstdatabank.com/customer_support/drug_pricing_policy/ [Accessed 2005 Jun 21]
13. Abelson R. Drug sales bring huge profits and scrutiny to cancer doctors. New York Times 2003 Jan 26
14. Centers for Medicare and Medicaid Services. Medicare Utilization for Part B (Supplementary Medical Insurance SMI) [online]. Available from URL: http://www.cms.hhs.gov/statistics/feeforservice/ [Accessed 2003 Aug 2]
15. Gencarelli DM. Average wholesale price for prescription drugs: is there a more appropriate pricing mechanism? NHPF Issue Brief 2002 Jun 7; (775): 1-19
16. Hawryluk M. Medicare aims to fix doctor drug payments [online]. Available from URL: http://www.ama-assn.org/amednews/2002/11/25/gvsc1125.htm [Accessed 2003 Jan 8]
17. Office of Inspector General. Medicare reimbursement of prescription drugs [report no. OE1-03-00-00310]. Washington, DC: Department of Health and Human Services, 2001 Jan
18. Stinson TJ, Calhoun E, Yang T, et al. Cost analysis of second-line therapies for platinum-refractory ovarian cancer: reimbursement dilemmas for Medicare patients. Cancer Invest 1999; 17 (8): 559-65
19. Managed Care Consultant. Impact of ACR guidelines on prescribing practices [online]. Available from URL: http://www.princetonhcm.com/public/2002- 20/report75.html [Accessed 2003 Jan 15]
20. Werner RM, Alexander GC, Fagerlin A, et al. The 'hassle factor': what motivates physicians to manipulate reimbursement rules. Arch Intern Med 2002; 162 (10): 1134-9
21. American Society of Hematology. Access to cancer therapies act of 2001 fact sheet [online]. Available from URL: http://www.hematology.org/government/ acti on_alerts/cta01_factsheet.cfm [Accessed 2003 Feb 6]
22. Life Raft Group. Medicare coverage of Gleevec sought [online]. Available from URL: http://www.liferaftgroup.org/Newsletters/Mar2002newsletter.pdf [Ac-cessed 2003 Feb 6]
23. Newhouse JP. How much should Medicare pay for drugs? Health Aff (Millwood) 2004; 23 (1): 89-102
24. Bowers ML, Siberman G, Mortenson LE. Oral oncology products: barriers to successful adoption [online]. Available from URL: http://www.elmservices.com/ documents/ELMOralonc.pdf [Accessed 2003 Feb 6]
25. Hawryluk M. Medicare drug pricing fix could threaten physician pay [online]. Available from URL: http://www.ama-assn.org/amednews/2002/04/01/ gvse0401.htm [Accessed 2003 Jan 13]
26. Finkelstein JB. Medicare doctor payments contribute to Part B premium rise [online]. Available from URL: http://www.ama-assn.org/amednews/2004/09/27/ gvsc0927.htm [Accessed 2004 Sep 28]
27. Medicare Payment Advisory Commission. Report to the Congress: benefit design and cost sharing in Medicare Advantage plans [online]. Available from URL: http://www.medpac.gov/publications/congressional_reports/Dec04_CostShari ng.pdf [Accessed 2005 Jun 21]
28. PriceWaterhouseCoopers. Estimate of savings to the Medicare Program from payment changes for covered outpatient drugs and biologicals under the Medicare Modernization Act of 2003. Prepared for: The Community Oncology Alliance [online]. Available from URL: http://healthcare.pwc.com/cgi-local/hcregister. cgi?link=pdf/mmasavings.pdf [Accessed 2005 Jun 21]
29. Thomas B. Medicare prescription drug, improvement, and Modernization Act of 2003 [online]. Available from URL: http://waysandmeans.house.gov/media/pdf/ healthdocs/awpreform.pdf [Accessed 2004 Jun 1]
30. Medlearn Matters MM3192. MMA: Payment for chemotherapy administration services, nonchemotherapy drug infusion services, and drug injection services [online]. Available from URL: http://www.cms.hhs.gov/medlearn/matters/ mmarticles/2004/MM3192.pdf [Accessed 2004 Aug 6]
31. Tempero MA. Summary of Medicare fee schedule rule [online]. Available from URL: http://www.asco.org/ac/1,1003,_12-002031-00_18-0031817-00_19-003 1818-00_20-001,00.asp [Accessed 2004 Aug 6]
32. Gatty B. Reimbursement for cancer drugs drops to 85% of AWP [online]. Availa-ble from URL: http://www.urologytimes.com/urologytimes/article/article Detail.jsp?.id = 81737 [Accessed 2004 Jun 1]
33. US General Accounting Office. Medicare: payments for covered outpatient drugs exceed providers cost [report no. GAO-01-1118]. Washington, DC: US General Accounting Office, 2001
34. US General Accounting Office. Medicare outpatient drugs: program payments should better reflect market prices [report no. GAO-02-53IT]. Washington, DC: US General Accounting Office, 2002 Mar
35. Trude S, Ginsburg PB. Growing physician access problems complicate Medicare payment debate. Issue Brief Cent Stud Health Syst Change 2002; (55): 1-4