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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 PDFAn Automated Clinical Laboratory Decision Support System for Test Utilization, Medical Necessity Verification and Payment Processing.
Interact J Med Res
January 2025
University of California, San Francisco, Department of Laboratory Medicine, San Francisco, US.
Physicians could improve the efficiency of the healthcare system if a reliable resource were available to aid them in better understanding, selecting, and interpreting the diagnostic laboratory tests. It has been well established and widely recognized that (a) laboratory testing provides 70-85% of the objective data that physicians use in diagnosis and treatment of their patients, (b) orders for laboratory tests in the U.S.
View Article and Find Full Text PDFUse and Costs of Supplemental Benefits in Medicare Advantage, 2017-2021.
JAMA Netw Open
January 2025
Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts.
Importance: Nearly all Medicare Advantage (MA) plans offer dental, vision, and hearing benefits not covered by traditional Medicare (TM). However, little is known about MA enrollees' use of those benefits or how much they cost MA insurers or enrollees.
Objective: To estimate use, out-of-pocket (OOP) spending, and insurer payments for dental, hearing, and vision services among Medicare beneficiaries.
2025: Who Can Separately Charge Medicare for Wound and Lymphedema Supplies?
Adv Skin Wound Care
January 2025
Kathleen D. Schaum, MS, is President and Founder of Kathleen D. Schaum & Associates, Inc, Lake Worth, Florida. Ms. Schaum can be reached for questions and consultations by calling 561-670-7176 or through her email address: Submit your questions for Payment Strategies by mail to Kathleen D. Schaum, MS, 6491 Rock Creek Dr, Lake Worth, FL 33467. This article is considered expert opinion and was not subject to peer review.
High-Cost Cancer Drug Use in Medicare Advantage and Traditional Medicare.
JAMA Health Forum
January 2025
Department of Health Systems, Management, and Policy, University of Colorado Cancer Center, Aurora.
Importance: Medicare Advantage (MA) plans are designed to incentivize the use of less expensive drugs through capitated payments, formulary control, and preauthorizations for certain drugs. These conditions may reduce spending on high-cost therapies for conditions such as cancer, a condition that is among the most expensive to treat.
Objective: To determine whether patients insured by MA plans receive less high-cost drugs than those insured by traditional Medicare (TM).
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