'Doc fix' reform bill alters Medicare reimbursement for some oral-only meds

The elimination of the Medicare Sustainable Growth Rate (SGR) formula that threatened large Medicare reimbursement cuts to doctors on an annual basis is the most significant entitlement reform achieved by the new Congress. As is often the case with important laws, the bill contained tangentially related items, and one of them affects reimbursement of oral-only renal dialysis drugs. The oral dialysis drugs that do not have an injectable equivalent will not be included in Medicare's payment bundle for end-stage renal disease (ESRD) until 2024. They were scheduled for inclusion in the program in 2016. Now, the oral-only meds will continue to be paid separately under Medicare Part D, they will not be part of a bundled payment system that tends to reduce reimbursement. In addition, the secretary of the Department of Health and Human Services, Sylvia Mathews Burwell, is tasked with creating outcome-based measures specific to conditions treated with oral-only drugs. In 2016, the measures will be added to the "total performance score" used to assess renal dialysis facilities. Those that fail to meet the total performance score already see their reimbursement under the ESRD Prospective Payment System cut by up to 2%. These tweaks are an example of the SGR bill's focus on value-based healthcare and a reminder to read (or at least inspect) bills carefully for small changes that don't make the headlines. Read the relevant section of the law | Here's more information about ESRD Prospective Payment System

Suggested Articles

Adamis Pharmaceuticals' EpiPen contender Symjepi, which was rejected last year before the EpiPen havoc, won approval from the FDA.

It’s not exactly going to be smooth sailing for Allergan’s multidose bottle version of dry-eye med Restasis. As it finally gets the green light from the FDA, a…

Counting on a novel nasal-spray device to set it apart from its rivals, drug delivery specialist OptiNose is preparing to file its new chronic rhinosinusitis…