The healthcare industry’s claims-payment system is frustrating to providers, payers, and patients alike. Inefficiency and a systemwide tendency for error wastes resources, worsens miscommunication and mistrust among all stakeholders, and inhibits the ability to transition to value-based approaches that achieve better outcomes.
Learn how the drive for accurate adjudication across the claims-payment continuum can optimize processes, reduce costs, align systems and stakeholders, and bring value-based payment models to scale.
With many payers focusing resources on a small percentage of chronically ill patients, a large portion of the member population remains unmonitored and engaged.
Patient engagement programs that are scalable, multi-layered, and tech-enabled to reach members in the most convenient and effective ways are essential to creating a positive member experience, driving loyalty, cost reduction, and better adherence.
As the largest payer of healthcare services in the United States, the Centers for Medicare and Medicaid Services (CMS) oftensets trend for healthcare delivery and reimbursement.
Over the past few years, there has been talk about Medicare reform and how to better pay for value. But we don’t always take the time to step back and appreciate what works well in Medicare and what has been emulated by other stakeholders.
For example, when Congress enacted the Average Sales Price (ASP) reimbursement methodology for Part B drugs in 2003, many commercial payers followed suit. This was with good reason: ASP is a transparent and stable metric that aligns reimbursement with market prices. Most recently, Medicare has again led the charge in adopting value-based reforms,creating ripple effects throughout the healthcare marketplace.
Four areas where we think Medicare has got it right are reimbursing physician-administered drugs, enabling beneficiary choice through Medicare Advantage, looking at total cost of care and tying payment to quality.
This paper is a companion piece to a detailed background paper on the use of real-world evidence in coverage decisions developed for the ICER Policy Summit held in December 2017.
This paper presents a new conceptual framework to address three elements largely missing from these earlier efforts focused on defining “best practices” or “standards” for RWE:
- How to understand the role that contextual factors play in determining how high the evidentiary standard, or “bar” will be in each situation;
- How to tailor key process and methodological approaches to the height of that evidentiary bar; and
- How to ensure that broader process principles that support transparency are integrated successfully throughout the course of any RWE initiative.
This guide lists the quality measure areas that can quickly and easily be impacted by mPulse Mobile solutions for each quality measure set and provides an overview of how these programs can be structured.
This paper sets out the potential opportunities and important challenges and limitations that must be addressed in considering options for using RWE to inform insurer coverage decisions.
The primary purpose of developing the paper was to stimulate discussion at the 2017 ICER Policy Summit meeting.
A separate paper is available that summarizes the authors reflections and proposed ways forwards based on the discussions that were had at the meeting.
The first human genome was sequenced in 2001 at a cost of $3 billion. Today, human genome sequencing costs less than $1000, and in a few years the price will drop below $100. Thus, personal genome sequencing will soon be widely adopted as it enables better diagnosis, disease prevention, and personalized therapies.
Furthermore, if genomic data is shared with researchers, the causes of many diseases will be identified and new drugs developed. These opportunities are creating a genomic data market worth billions of dollars.
Nebula Genomics seeks to lead this emerging market by understanding and overcoming key obstacles. We will spur genomic data growth by significantly reducing the costs of personal genome sequencing, enhancing genomic data protection, enabling buyers to efficiently acquire genomic data, and addressing the challenges of genomic big data.
We will accomplish this through decentralization, cryptography, and utilization of the blockchain.
The affordability of healthcare and biopharmaceutical drugs is a top concern for Americans.
It is often asserted that promoting innovation and affordable drugs are conflicting goals. New innovations, however, often provide improved health that was not previously available at any price or obviate the need for more costly care.
They thereby lower the effective price of health down to the price of the patented drugs, and later down to the price of generic drugs. Federal policies that affect drug pricing should satisfy two goals.
First, domestic drug prices paid by Americans should be reduced. Second, the price of better health in the future should also be reduced by spurring medical innovation. This report considers policy options to simultaneously advance these two seemingly conflicting goals.
What’s old is new again, and value-based drug pricing is anticipated to be the cornerstone of a soon-to-be-released U.S. presidential executive order on drug pricing. Building on consultation with industry and government experts, the executive order is the policy follow-up to statements from President Trump’s Jan. 11 press conference promising to “create new bidding procedures for the drug industry because they’re getting away with murder” that will “save billions of dollars over a period of time.” Simply by placing the terms value and pricing in proximity, the initiative generates hope that drugs will become a better value for patients and that recent examples of exploitive pricing (e.g., Daraprim, EpiPen) don’t become a regular occurrence. But is valuebased pricing really a prescription for large-scale savings?
When leading biopharma companies founded SAFE-BioPharma in 2005, it was with a vision of a not too distant future with major changes in the industry: the move to collaboration with many partners, make business processes fully electronic, and to take advantage of all of the benefits of online operations. It’s safe to say that the rate and scale of the digital revolution was even greater than most observers predicted, but this foresight proved correct.