Decoding Medicare: 10 key decisions and how they're made


Decoding Medicare: 10 key decisions and how they're made

Will Medicare pay? The answer to that question often means success or failure for novel drugs and devices, influences the choices made by private insurance plans, and affects the adoption of emerging technologies like gene and cell therapies and artificial intelligence.

But Medicare’s decisions about coverage usually come wrapped in all-but-impenetrable directives and policy statements, accompanied by a slew of acronyms.

This report was designed to guide you through the Medicare maze, deciphering its insider terminology and showing you how the massive federal program decides what to cover and which entities lie behind those determinations.

Written by Kerry Dooley Young, a reporter who has covered Medicare for almost two decades, it is an essential resource for anyone involved or simply interested in health care or health policy — especially at a time when Medicare is demanding more evidence for the safety and effectiveness of new products, even those already approved by the Food and Drug Administration.

This report is for:

  • Biotech and pharmaceutical company leaders, whose drug or device development often hinges on obtaining Medicare coverage
  • Hospitals executives, physicians and other medical professionals, whose reimbursement for novel treatments may be affected by Medicare’s coverage decisions
  • Patients with Medicare or Medicare Advantage plans hoping to obtain coverage for new drugs and devices
  • Anyone interested in health care and health care policy who wants to understand how Medicare operates and how the federal program will handle today’s rapid advances in medical technology

In this report, you will find:

  • A breakdown of 10 important decisions Medicare has made or is in the process of making, including recent ones on Biogen’s Alzheimer’s drug Aduhelm, CAR-T, and popular weight loss drugs.
  • An explanation of what Medicare’s new demand for more evidence means for drug and device makers.
  • A glossary of the acronyms that make up Medicare-speak.
  • An analysis of how Medicare defines “necessary and reasonable.”