Module 5
The Policy Layer
The Part D redesign moved catastrophic risk onto plans, Medicare began negotiating prices directly, and a closing assessment of what a risk-bearing organization can actually do.
By the end of this module, you will be able to:
- Trace how capping beneficiary cost reassigned risk and changed plan behavior
- State what Medicare price negotiation covers and what it does not
- Build a drug strategy around what an organization can influence
- The Part D Redesign Capping what beneficiaries pay moved catastrophic risk onto plans. That reassignment changed plan behavior more than the cap changed patient behavior. About 5 min
- Medicare Drug Price Negotiation For the first time Medicare negotiates prices directly for selected drugs. The mechanism is narrow, the precedent is not. About 5 min
- Pharmacy Spend: An Honest Scorecard The capstone, and the end of the curriculum: what a risk-bearing organization can actually do about drug spend, and what it cannot. About 5 min
Module quiz
Answer all questions to see your score.
1. What did the Part D redesign do to Medicare's catastrophic reinsurance?
Plans responded with tighter formularies, more utilization management, and harder rebate negotiation. You cannot cap what one party pays without deciding who absorbs it.
2. Which drugs are eligible for Medicare price negotiation?
Ten Part D drugs had negotiated Maximum Fair Prices effective January 1, 2026. The scope is narrow; the precedent for federal drug pricing is the larger consequence.
3. What is the most common error organizations make about drug spend?
Organizations that handle drug spend well are precise about what they influence, finance what they cannot, and spend management attention entirely on the first category.