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Medicare
Part B
What is Medicare Part B?
Medicare Part B is commonly referred to as the Medicare medical benefit and covers a wide range of health care items and services including physician office visits, outpatient care, ambulance services and medical equipment like a wheelchair or walker. Typically, treatments covered under Part B are administered in a physician’s office or hospital outpatient setting.
Most medicines covered by Part B covers are administered by a physician, like injected or infused chemotherapy medications. These medicines represent some very significant medical advances, including breakthroughs in cancer, rheumatoid arthritis and autoimmune conditions. Patients may receive these medicines across a number of different care settings.
Part B and Medicare Part B Costs
Part B Spending in Context
Medicare payment for medicines covered under Medicare Part is based on the medicine’s Average Sales Price (ASP), which reflects in general the weighted average of all manufacturer sales prices and includes all rebates and discounts that are privately negotiated between manufacturers and purchasers. This allows the government and beneficiaries to benefit from discounts negotiated on physician-administered medicines in the commercial market. In fact, an analysis found that the ASP reimbursement model saved the government and seniors a total of $132 billion from 2005 to 2017 in Part B medicine spending.
Spending on Part B medicines also continues to represent a small and stable share of overall Part B spending at only 10% in 2018. Recent research found the volume-weighted average sales price for Part B medicines has remained steady year over year, suggesting that prices for prescription medicines and biologicals are not a key driver of program costs. This is in part because Medicare Part B benefits from brand and generic and biosimilar competition, as well as private negotiation between manufacturers and commercial payers.
Proposed Changes to Part B
Right Ways and Wrong Ways to Modernize Part B
The market-based system used to reimburse providers for medicines under Part B has been successful at managing costs while supporting timely access to innovative medicines for beneficiaries, but there are also ways it could work better. We support reforms that enable Medicare and Medicare beneficiaries to benefit more from the lower prices negotiated by large commercial purchasers in the market, while protecting physician care quality and patient access. Learn more about those reforms here.
However, there have been a number of recent proposals to alter the Part B program that would put patients at risk. Proposals that rely on government price setting policies, under the guise of “negotiation” are the wrong approach. Whether through international reference pricing or other mechanisms, they threaten patients’ access to treatments and cures. For example:
- Restricted access to new medications. While nearly 90% of new medicines launched globally in the past decade are currently available to patients in the United States, only about half are available to patients in other countries like France and Canada.
- Delays in receiving new medicines. While new cancer medicines are available in the United States, on average, within two months of approval, patients in other countries face significant delays. Patients in Germany, for example, wait 11 months on average for new cancer medicines to become available, and patients in France wait 14 months on average.
