Spotlight on Market Access

As Medicare Advantage insurers seek ways to maximize revenue in a fiscally challenging environment, the accurate and complete capture of diagnosis codes is paramount. That’s because their reimbursement is dependent on the documented health of their enrollees and related risk scores. But risk adjustment comes with inherent compliance risks, demonstrated by pending lawsuits involving the use of chart review and addenda programs and a recent settlement involving whistleblower Teresa Ross, a former MA plan employee who spoke at the 2025 RISE National conference.

“It’s a very isolating and lonely time. The whole time the company is gaslighting you. You say too much, so then you get excluded from meetings,” said Ross. At one point, her employer sent a mental health counselor to her office “to try to tell me that I was wrong for not going along,” she recalled.

The America First Policy Institute, a think tank founded by former advisers to President Donald Trump, recently released a paper that blamed foreign countries for pharmaceutical “global freeloading” and outlined several policy options to end it. Options included most-favored nation pricing and international reference pricing — two proposals raised during Trump’s first term.

The paper argued that this pharmaceutical freeloading occurs when other wealthy countries implement price controls that allow them to “have their cake and eat it too — to get lifesaving drugs for their citizens without paying the necessary costs to develop them.” It deprives drug manufacturers of billions of dollars and comes at the cost of new treatments for patients in the U.S. and abroad, the paper said.

Having a successful product launch and securing payer coverage come well before FDA approval of a drug. But some drugmakers face an uphill battle after launch because they fail to engage with both payers and patients in a timely fashion, as well as provide them with truly useful information.

To engage payers effectively, pharma companies should individualize their value propositions with a focus on what’s important to each one rather than a one-size-fits-all tactic, says Dominic Galante, M.D., chief medical officer at Precision AQ. He also recommends that manufacturers think beyond traditional pricing models and “adopt flexible pricing strategies and innovative reimbursement models that align with payer budgets and value-based care initiatives.”

The FDA recently approved a new combination treatment for a very small population of cancer patients that has dismal survival rates. In response to a Zitter Insights survey, most oncologists said they believe the new treatment will have at least some impact on their prescribing.

On Jan. 16, the FDA gave another approval to Amgen Inc.’s Lumakras (sotorasib) in combination with the company’s Vectibix (panitumumab) for the treatment of adults with KRAS G12C-mutated metastatic colorectal cancer (CRC), as determined by an FDA-approved test, who have received fluoropyrimidine-, oxaliplatin- and irinotecan-based chemotherapy.

In defiance of some industry watchers’ expectations, there was no mass exodus from stand-alone Prescription Drug Plans (PDPs) to Medicare Advantage Prescription Drug (MA-PD) plans between 2024 and 2025, one prominent Part D actuary has observed. 

“Total enrollment was effectively flat from December [20]24 to February 2025; that’s a little bit at odds with what some might have expected,” explains Brooks Conway, principal with Oliver Wyman.  

As for why enrollment trends this year defied expectations, Avalere Health Principal Robin Duddy-Tenbrunsel points out that “there’s been quite a bit going on” in the Part D world.