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SUMMARY
Introduction
In 2006, approximately 1.4 million U.S. residents are expected to be diagnosed
with some form of cancer. Medicare's role in oncology therapy is particularly
significant because it funds the treatment of about half of all U.S. cancer
patients. Recent changes to Medicare's drug reimbursement policies have
drastically altered the way treatment is financed and promise to shape the
future of cancer treatment in the United States.
Get the Answers You Need to Shape Your Strategy
Medicare, through its recent changes to its drug reimbursement policies, is
poised to increase its influence on oncology practice in the United States.
How do Medicare's new reimbursement policies affect oncology practices and
hospitals, commercial payers, pharmaceutical manufacturers, and patients?
Private payers are moving physician-administered drugs from the medical
benefit to the pharmacy benefit in an effort to contain costs. What types
of new therapies will benefit from this trend? How does this trend affect the
reimbursement of existing therapies? The rapidly changing reimbursement
environment presents manufacturers of oncology drugs with considerable
challenges. What new factors must drug manufacturers consider when setting
pricing policies for therapies?
Scope
- Medicare coverage of oncology treatment: how changes in
reimbursement policies have affected office-based treatment, hospital
outpatient treatment, hospital inpatient treatment, and self-administered
drugs (Medicare Part D).
- Private sector coverage of oncology treatment: physician
reimbursement, distribution controls, cost sharing.
- Off-label prescribing: how coverage of off-label usage by both
Medicare and private payers affects oncologists' prescribing behaviors.
- Outlook and implications for the pharmaceutical industry: new
trends in the classification of treatments, setting of drug prices, and the
launch of new therapies.
TABLE OF CONTENTS
- Executive Summary
- Strategic Considerations
- Stakeholder Implications
- Introduction
- Medicare
- Office-Based Treatment
- Physician Reimbursement
- Patients' Out-of-Pocket Payments
- Competitive Acquisition Program .
- Demonstration Projects
- Hospital Outpatient Treatment
- Hospital Inpatient Treatment
- Self-Administered Drugs (Medicare Part D)
- Private Sector
- Physician Reimbursement
- Distribution Controls
- Cost Sharing
- Off-Label Prescribing
- Outlook and Implications for the Pharmaceutical Industry
- Appendix: Medicare Spending on Inpatient Cancer Treatments
Tables
- 1. Average Price Variations for Select Oncology Drugs Under Medicare Part
B, December 2004 and June 2005
- 2. Net Payments to Oncologists Based on Varying Levels of Coinsurance
Nonpayment
- 3. Technologies with Pass-Through Status in the Medicare Outpatient
Prospective Payment System, 2006
- 4. Key Features of Medicare Inpatient and Outpatient New Technology
Payment Mechanisms
- 5. Formulary Positioning and Copayments for Select Cancer Therapies in
Medicare Part D Prescription Drug Plans
- 6. U.S. Health Plans' Reimbursement Rates for Physician-Administered
Drugs, 2002
Figures
- 1. Main Sources of Insurance Coverage for Breast Cancer Therapy, 2006
- 2. Main Sources of Insurance Coverage for Skin Cancer Therapy, 2006
- 3. Main Sources of Insurance Coverage for Prostate Cancer Therapy, 2006
- 4. Main Sources of Insurance Coverage for Lung Cancer Therapy, 2006
- 5. Main Sources of Insurance Coverage for Colorectal Cancer Therapy, 2006
- 6. Main Sources of Insurance Coverage for Breast, Skin, Prostate, Lung,
and Colorectal Cancer Therapy, 2006
- 7. Evolution of Medicare Part B Spending on Oncology Drugs, 1999-2004
- 8. Private Health Plans' Average Reimbursement Rates for Oncology Drugs,
Fall 2004 and 2005
- 9. Circumstances in Which HMO Pharmacy Directors Would Authorize Off-Label
Use of Oral Chemotherapeutic Agents, 2005 .
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