In 1987, the Texas Medical Association and 20 other plaintiffs filed suit against the US Department of Health and Human Services (HHS) over the federal government's effort to recoup $14 million from physicians and patients for alleged overpayments during July 1985 through March 31, 1986. A federal district court judge granted a preliminary injunction that halted the recoupment pending a full hearing on the merits of the case and a decision. In June 1989 the Court of Appeals overturned the district court's decision, and TMA turned to the US Congress for relief. This article summarizes recent judicial and legislative progress in halting the recoupment.
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Importance: Biologics approved by the US Food and Drug Administration (FDA) receive 12 years of guaranteed protection from biosimilar competition compared with 5 years of protection from generic competition for new small-molecule drugs. Under the 2022 Inflation Reduction Act, biologics are exempt from selection for Medicare price negotiation for 11 years compared with 7 years for small-molecule drugs. Congress codified these differing legal protections on the premise that biologics require more time and resources to develop and have weaker patent protection, necessitating additional protections for manufacturers to recoup their development costs and generate adequate returns on investment.
View Article and Find Full Text PDFJ Occup Environ Med
July 2024
CNOS Occupational Medicine, Dakota Dunes, SD.
Clinical practices that provide workers' compensation care and other services related to managing work-related illnesses and injuries have long been challenged in receiving appropriate payment for their professional work. The American College of Occupational and Environmental Medicine (ACOEM) has provided excellent guidelines for coding and billing via its various documents that have been provided over the years. However, despite these guidelines, payors have been slow to adopt occupational specific coding guidelines to justify higher professional payment.
View Article and Find Full Text PDFJAMA Surg
May 2024
Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston.
J Health Polit Policy Law
December 2023
The Medicare Advantage program was created to expand beneficiary choice and to reduce spending through capitated payment to private insurers. However, many stakeholders now argue that Medicare Advantage is failing to deliver on its promise to reduce spending. Three problematic design features in Medicare Advantage payment policy have received particular scrutiny: (1) how baseline payments to insurers are determined, (2) how variation in patient risk affects insurer payment, and (3) how payments to insurers are adjusted for quality performance.
View Article and Find Full Text PDFNeurol Clin Pract
December 2022
Skaggs School of Pharmacy and Pharmaceutical Sciences (RBM), University of Colorado Anschutz Medical Campus, Aurora; Department of Health Care Policy and Research (MG, MM), University of Colorado Anschutz Medical Campus, Aurora; Departments of Neurology and Neurosurgery (DK), University of Colorado Anschutz Medical Campus, Aurora; Swedish Medical Center (JLB), Family Residency Program, Denver, CO; Pharmacology Graduate Program (IS), University of Colorado Anschutz Medical Campus, Aurora; and Departments of Neurology and Medicine (BMK), University of Rochester Medical Center, NY.
Implementation of palliative care (PC) in neurology settings may improve symptom control and quality of life and reduce acute care admissions. The benefits of team-based PC for patients with Parkinson disease have been established through rigorous evidence standards including randomized controlled trials. However, evidence on implementation costs and return on investment (ROI) is unknown and may guide other providers and systems considering this model of care.
View Article and Find Full Text PDFEnter search terms and have AI summaries delivered each week - change queries or unsubscribe any time!