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>>  4.1 Encouraging Use of Generic Drugs
  • Adjust the Medicare Part D low-income subsidy cost-sharing and Part D plan payments to encourage the use of high-value drugs. [page 64] [Medicare] Read More >>
  • Form "accountable care states" with global targets for all health care spending by both public and private payers. Read More >>
  • Encourage generic competition by reducing the exclusivity period of biologics (medicines made in living cells rather than from a mixture of chemicals) from 12 to seven years. [page 22] Read More >>
  • Encourage faster introduction of generic drugs. Prohibit the practice of "pay for delay," where name-brand drug manufacturers pay generic companies to delay introduction of their drugs into the market. [page 27]
>>  4.2 High-Quality, Low-Cost Health Plans in State-Based Marketplaces
  • Enhance participation in non-group and small group insurance markets and reduce adverse selection through: effective broad-based outreach and default enrollment for individuals who are eligible for subsidies; limiting open enrollment periods to one to two months per year; limiting ability to shift to higher-value plans; relaxing the requirement for full community rating and the preexisting condition exclusion for consumers without continuous coverage; applying late enrollment penalties; and temporarily extending additional financial support for highest-risk individuals. [pages 27-28] [Private Payers]
  • Require health insurance exchanges and state employee plans to offer tiered insurance plans that designate providers with high quality and low costs for patients (at least one tiered product at the bronze and silver levels by 2016). Read More >>
  • Change payment of primary care to reward care management, coordination, and a team-based systemic approach to caring for patients under Medicare, Medicaid, other public programs, and private plans participating in health insurance exchanges. [pages 23-24] [Medicare, Medicaid, Private Payers, FEHBP] Read More >>
  • The U.S. Department of Health and Human Services and other federal agencies should accelerate efforts to promulgate the regulations and guidance needed for health insurance exchange implementation in each state. [page 19] [Private Payers] Read More >>
  • The new state health insurance marketplaces (also known as exchanges) should strongly encourage all participating health plans to offer a value-based insurance design (VBID) option by 2019 (VBID relies on clinical research and data on provider performance as the basis for offering incentives to consumers to use evidence-based treatments and services and to obtain care from providers with a demonstrated ability to deliver quality, efficient health care). Read More >>
>>  4.3 Regulatory Oversight
  • Limit the in-office self-referral exception to the Stark Law (allow only for providers who meet accountability standards in advanced payment models). [page 66] Read More >>
  • Update the antitrust enforcement framework to place greater emphasis on favoring clinical integration activities that are accompanied by financing reforms that move away from fee-for-service payments and place providers at financial risk for quality gaps and higher costs. Read More >>
  • Encourage more consistent payment approaches across payers to help counteract the concentration of provider market power; under state or federal government authority (to avoid antitrust violations), allow multiple payers to negotiate jointly to employ similar payment methods and more consistent pricing that promotes efficient care and value. [page 25] [Private Payers]
  • Empower the FTC to aggressively enforce existing antitrust laws and expand antitrust laws to combat market practices designed to frustrate competition on price and quality, such as anti-tiering and guaranteed inclusion clauses. [page 17] Read More >>
  • The Federal Trade Commission (FTC) should continue holding hearings on competition issues and market-based efforts to increase efficiency. Read More >>
>>  4.4 Competitive Bidding
  • Establish a standardized minimum benefit for Medicare Advantage (MA) plans—including all services covered by traditional Medicare, a cost-sharing limit to protect against catastrophic expenses, and slightly lower cost-sharing—and pay plans using a competitive-pricing system. Read More >>
  • Use competitive bidding for all health care products: (1) expand competitive bidding by 2014 for DME, prosthetics, orthotics, and supplies nationwide; (2) extend competitive bidding by 2015 to medical devices, lab tests, advanced imagine services, and all other health care products; (3) extend competitively bid prices to Medicaid and all other government health programs. [page 4] [Medicare, Medicaid, FEHBP] Read More >>
  • Institute competitive bidding in Medicare payment for medical commodities (drugs, equipment, and supplies). [page 23] [Medicare]
  • Expand competitive bidding to additional categories of DME in Medicare. Read More >>
  • Expand competitive bidding for medical devices, laboratory tests, radiologic diagnostic services, and various other commodities. [page 20] [Medicare] Read More >>
>>  4.5 Other Proposals for Enhancing Market Competition
  • Medicare Advantage: Implement a reinsurance system for Medicare Advantage (MA) by 2016, similar to the system in place for Medicare Part D. [page 45] [Medicare] Read More >>
  • Allow MA plans to return 100 percent of the difference between their bids and the benchmark to beneficiaries in the form of lower premiums (vs. 50% in the form of additional benefits) to encourage greater competition on price. [pages 20-21] [Medicare] Read More >>
  • Improve the Federal Employees Health Benefits (FEHB) Program and use it to reform health care delivery. FEHB should align with Medicare on payment reforms, metrics, and value-based purchasing. [page 11] [FEHBP, Private Payers]
  • Encourage private plans in each state to negotiate prices consistent with efficient care and value and not to just pass on higher prices to consumers. [page 25] [Private Payers] Read More >>
  • Integrate medication adherence measures into a variety of ongoing health care quality and value incentives, including the Hospital Value-Based Purchasing Program and the Readmissions Reduction Program. Read More >>
  • Give the U.S. Secretary of Health and Human Services the authority to better align Medicare clinical lab payments with the private sector. [page 27] [Medicare]
Source: Katie Horton, J.D., M.P.H., R.N., Mary-Beth Malcarney, J.D., M.P.H., and Naomi Seiler J.D., George Washington University Department of Health Policy.