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Payment models and the sustainability of community pharmacy practice: a qualitative interview study with community pharmacists.
J Pharm Policy Pract
January 2025
College of Pharmacy, University of Health Sciences and Pharmacy, St Louis, MO, USA.
Background: The sustainability of community pharmacies in the United States depends, in large part, on policies enacted by the Centers for Medicare and Medicaid Services (CMS). In 2003, CMS policy allowed retrospective direct and indirect remuneration (DIR) fees to manage costs. From 2024, only prospective DIR fees are permitted.
View Article and Find Full Text PDFStaffing Up: The Nursing Home Minimum Staffing Rule.
J Gen Intern Med
January 2025
Brown University, 222 Richmond St., Providence, RI, 02903, USA.
On April 22, 2024, the Centers for Medicare & Medicaid Services (CMS) announced new staffing mandates for long-term care (LTC) facilities in an effort to improve care quality in nursing homes (NHs). The guidelines require a minimum of 3.48 h of daily care per resident, including 0.
View Article and Find Full Text PDFMedicare Risk Adjustment: Goals, Reform Proposals, And New Frontiers.
Health Aff (Millwood)
January 2025
Aaron L. Schwartz University of Pennsylvania and Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania.
Risk adjustment modifies payments to health insurers based on enrollee characteristics that are predictive of higher or lower medical spending. Risk-adjustment policy is a key ingredient for the success of regulated individual insurance markets in Medicare and beyond. Researchers have identified shortcomings of Medicare's current risk-adjustment system, illustrated the limits of coarse fixes, and proposed new strategies that improve the data and calculations used to generate beneficiary risk scores.
View Article and Find Full Text PDFAccelerating biosimilar market access: the case for allowing earlier standing.
J Law Biosci
January 2025
Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, 1620 Tremont St. Suite 3030, Boston, MA 02120, USA.
Biosimilars, which are affordable alternatives to biologic medicines, face delays in market entry due to the current patent litigation framework under the Biologic Price Competition and Innovation Act. Currently, biosimilar manufacturers can only initiate patent litigation to attempt to clear weak and invalid patents after submitting their Biologic License Application to the Food and Drug Administration (FDA), which happens after completing extensive, and costly clinical trials. By contrast, generic drug manufacturers can start litigation earlier due to shorter development times and less stringent clinical requirements, allowing them to launch immediately after the primary patent expires.
View Article and Find Full Text PDFThe Burden of Insurance Prior Authorization on Cancer Care: A Review of Evidence From Radiation Oncology.
Adv Radiat Oncol
January 2025
Department of Radiation Oncology, Vanderbilt University School of Medicine, Nashville, Tennessee.
Purpose: Despite its high cost-effectiveness, radiation oncology faces the greatest prior authorization (PA) burden of any medical specialty. Insurance denials and resulting treatment delays have been documented across several treatment modalities, including stereotactic body radiation, intensity modulated radiation, and proton therapy. Although insurance companies suggest that PA is intended to control health care spending and ensure the implementation of evidence-based practice, the number of radiation treatment plans reviewed by the PA process that result in changes is quite low.
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