MedPAC’s July 2026 Data Book: What Access Professionals Need to Know
A practical, field-focused summary of the Medicare spending, beneficiary, access, Medicare Advantage, provider, and prescription drug trends most relevant to Access & Reimbursement Managers, Field Reimbursement Managers, healthcare-office stakeholders, specialty pharmacies, providers, and the patients they serve.
The Medicare environment in five numbers
The report’s most important message is not a single policy change. It is the growing scale, financial pressure, clinical complexity, and operational importance of the Medicare program.
PharmaARMs Perspective
For field access professionals, these data point toward a Medicare environment in which utilization, documentation quality, benefit design, network status, site of care, product channel, affordability, and provider economics will remain closely examined.
The practical response is not to predict coverage decisions. It is to strengthen benefit verification, documentation readiness, authorization workflows, escalation pathways, appropriate site options, claims follow-up, and communication with healthcare-office stakeholders.
Medicare is becoming a larger part of the economy
Medicare covered about 16% of the U.S. population in 2024 but paid 23% of national personal healthcare spending, reflecting the older age and generally higher healthcare needs of its population.
What the data show
- Medicare paid approximately $1 trillion toward personal healthcare in 2024.
- Medicare spending represented 3.9% of GDP in 2025.
- Spending is projected to rise from approximately 4% to 5% of GDP within about one decade.
- The Medicare population is projected to continue growing as the baby-boom generation reaches eligibility age.
- Medicare Part A financing faces long-term pressure as the number of workers per beneficiary declines.
What appears to be driving growth
After removing economy-wide inflation, MedPAC’s presentation identifies beneficiary growth and a broad “other” category as major drivers.
That “other” category includes changes in the volume and intensity of services and items furnished, including growth in the average amount Medicare pays for Part B drugs.
In other words, the projected pressure is not explained solely by Medicare payment-rate updates.
Why this matters in access and reimbursement
Continued spending growth increases the likelihood of sustained attention to payment adequacy, utilization, product pricing, diagnostic coding, alternative payment models, care setting, avoidable services, and administrative efficiency.
Access teams should expect benefit and authorization requirements to remain dynamic. Current coverage criteria, payer portals, published medical policies, plan documents, CMS guidance, and applicable contractor instructions should always be verified for each case.
Part B drugs are the clearest field-relevant spending signal
Among the service categories examined, physician-administered drugs covered under Part B had the fastest inflation-adjusted growth in FFS spending per beneficiary between 2015 and 2023.
Where 2024 Part B spending was concentrated
Total FFS Medicare payments for Part B drugs, biologics, and related products were reported at approximately $65.5 billion in 2024.
- Antineoplastics represented approximately $22.7 billion and 35% of total Part B drug spending.
- Skin substitutes represented approximately $10.1 billion in 2024 after exceptionally rapid growth.
- Ophthalmic agents represented approximately $6.2 billion.
- The 10 leading therapeutic classes accounted for roughly 90% of Part B drug spending.
The therapeutic categories reported also included endocrine agents, hematological agents, immune globulins, vaccines, neuromuscular and musculoskeletal agents, and respiratory therapies.
FRMs and ARMs
Greater need for precise benefit-channel identification, coverage verification, coding-resource awareness, documentation readiness, and compliant support of provider-office workflows.
Providers and practices
Greater sensitivity to acquisition costs, payment timing, claim accuracy, denials, appeal workload, inventory exposure, and the financial effect of treatment setting.
Payers and health plans
Ongoing incentives to evaluate medical necessity, utilization, preferred products, biosimilar competition, provider networks, and site-of-care arrangements.
Patients
Potential effects on treatment start time, travel requirements, care setting, cost-sharing exposure, provider choice, and continuity of therapy.
PharmaARMs Perspective
Part B drug growth does not automatically establish that a particular payer will implement a new restriction. It does, however, explain why physician-administered drugs and biologics are likely to remain central to discussions involving biosimilars, payment methodology, utilization controls, medical-benefit management, care setting, and total cost of care.
Field teams should prepare healthcare-office stakeholders to distinguish between medical and pharmacy benefit pathways, understand product-specific billing requirements, verify plan and network rules, identify appropriate care-setting options, and maintain complete documentation before treatment.
Do not overinterpret the 8% figure
The 8% figure describes historical growth in inflation-adjusted spending per FFS beneficiary for physician-administered Part B drugs. It is not a projection that every Part B drug, therapeutic class, or individual product will grow by 8%, and it does not establish a coverage or reimbursement policy.
Managed care now shapes a large share of Medicare access
The Data Book documents the continued scale of Medicare Advantage, including enrollment, plan availability, payments, coding, selection, special-needs plans, and prior-authorization activity.
Scale of the program
- Medicare paid MA plans an estimated $537 billion in 2025 for Part A and Part B services.
- Total estimated payments to MA plans more than doubled from 2019 through 2025 on a nominal basis.
- Medicare managed care was the main coverage arrangement for a majority of beneficiaries in MedPAC’s 2023 supplemental coverage analysis.
- Special-needs plans and employer group plans represent important MA submarkets with distinct beneficiary profiles.
Operational relevance
- Plan-specific medical policies and authorization rules
- Network and site-of-service requirements
- Plan-directed specialty pharmacy arrangements
- Differences among HMO, PPO, SNP, and employer plans
- Appeal, reconsideration, and escalation processes
- Annual plan changes and beneficiary transitions
PharmaARMs Perspective
A Medicare card alone is no longer enough to determine the operative access pathway. Teams must establish whether the beneficiary is enrolled in Original Medicare or an MA plan, identify the exact plan and product, confirm network status, and review current authorization and site-of-care requirements.
When an authorization is denied, healthcare-office teams should document the stated reason, obtain the plan’s applicable criteria, determine whether information was missing, distinguish clinical denials from administrative denials, and follow the plan’s published appeal process and deadlines.
Prior authorization data require context
Aggregate prior-authorization volumes or denial rates do not describe the experience of every plan, service, therapeutic area, or patient. Plan-level criteria and the facts of each case remain essential.
Part D redesign is changing costs, premiums, and plan behavior
The Data Book documents Part D enrollment, premiums, low-income subsidies, plan benefit design, spending, rebates, pharmacy fees, product mix, and postlaunch price trends.
Spending trend
Gross Part D spending per enrollee per month rose from approximately $290 in 2015 to $442 in 2024.
That represents approximately 4.8% average annual nominal growth, or about 53% cumulatively over the period.
Gross spending includes payments at the point of sale from beneficiaries and other payers but excludes certain postsale manufacturer rebates and pharmacy fees.
Benefit-design considerations
- Medicare policies have materially affected reported Part D premiums.
- Coinsurance is increasingly used for some brand-name and nonpreferred tiers.
- Low-income subsidy benchmarks and qualifying plan availability vary by region.
- Rebate and pharmacy-fee dynamics can create differences between point-of-sale prices and net program costs.
PharmaARMs Perspective
Part D affordability cannot be assessed from a drug’s list price alone. The relevant patient experience depends on the selected plan, formulary placement, tier, deductible, coinsurance or copay, utilization-management requirements, preferred pharmacy status, subsidy eligibility, benefit phase, and current Medicare Prescription Payment Plan rules.
Provider-office stakeholders should be supported with current, plan-specific information and should avoid promising coverage, exact patient cost, approval, or payment before verification.
A relatively small population accounts for most spending
High spending is concentrated among beneficiaries with complex medical, functional, financial, or coverage needs—the same populations that frequently require the most intensive access and reimbursement support.
Concentration of FFS spending
- The costliest 1% of beneficiaries accounted for approximately 17% of FFS program spending in 2023.
- The costliest 5% accounted for approximately 45%.
- The costliest 25% accounted for approximately 84%.
- The least costly 50% accounted for only about 4%.
Populations associated with higher spending
- Beneficiaries with multiple chronic conditions
- Beneficiaries using inpatient hospital services
- People eligible through disability or ESRD
- Dually eligible Medicare and Medicaid beneficiaries
- Beneficiaries in the final year of life
Dually eligible beneficiaries are more likely to have poor health, disability, lower income, and complex coordination needs across Medicare and Medicaid.
Cost-sharing exposure differs substantially depending on whether a beneficiary has Medicaid, Medigap, employer coverage, managed care, another public source, or Medicare alone.
MedPAC’s survey indicates that lower-income beneficiaries reported obtaining less care than higher-income beneficiaries, even where overall Medicare access measures were comparatively favorable.
PharmaARMs Perspective
Administrative complexity can have its greatest effect on people already facing clinical complexity, disability, limited income, fragmented coverage, transportation limitations, or multiple care settings.
Access professionals can support healthcare-office stakeholders by helping them understand benefit pathways, identify missing information, recognize available escalation routes, and locate appropriate payer and program resources. All activity must remain within company policy, role boundaries, privacy requirements, and applicable law.
Financial conditions differ sharply across provider sectors
The Data Book shows that provider financial performance cannot be described with one universal Medicare margin. Results vary by hospital category, service line, ownership, geography, cost structure, case mix, payer mix, and care setting.
Hospital environment
Hospital all-payer operating margins improved in fiscal year 2024, but aggregate FFS Medicare hospital margins remained substantially negative, with meaningful variation among hospitals.
FFS Medicare hospital revenue has also continued shifting toward outpatient services.
Post-acute care environment
Financial results also varied across skilled nursing facilities, home health agencies, inpatient rehabilitation facilities, long-term care hospitals, and hospice organizations.
Some sectors reported relatively high aggregate FFS Medicare margins, while others faced declining use, changing case mix, or payment growth below cost growth.
Provider-office and stakeholder relevance
Provider economics can affect whether a practice or facility is able and willing to acquire, store, administer, and financially carry a physician-administered therapy. Access barriers may arise even when the drug itself is covered.
Relevant issues may include acquisition cost, reimbursement timing, patient cost sharing, claim-denial risk, coding uncertainty, staffing, chair capacity, network participation, drug sourcing, wastage, and care-setting requirements.
Coverage does not always equal operational access
A therapy may appear covered under a payer policy yet remain difficult to initiate because of authorization conditions, incomplete documentation, network restrictions, sourcing rules, provider financial exposure, appointment capacity, affordability, or coordination failures.
Effective access support requires understanding both the formal coverage policy and the real-world workflow required to move from prescription to treatment.
What access professionals should monitor next
The following issues are not presented as confirmed outcomes from the Data Book. They are practical areas to monitor because they intersect with the trends documented in the report.
Practical actions for access and reimbursement teams
The value of the report is not memorizing every number. It is using the broader trends to strengthen compliant access processes.
1. Confirm the exact benefit and plan before mapping the pathway
Determine whether the therapy is processed under the medical or pharmacy benefit, whether the beneficiary has Original Medicare or Medicare Advantage, whether supplemental coverage applies, and whether the provider and proposed site are in-network.
2. Build documentation readiness before submission
Review the current payer criteria and confirm that required diagnosis information, clinical history, testing, treatment history, dosing, site-of-care rationale, and supporting records are available to the healthcare-office team.
3. Separate administrative barriers from clinical-policy barriers
A denial caused by missing records, an invalid code, network status, lack of authorization, or submission error may require a different response from a denial based on medical-necessity criteria.
4. Understand the provider’s operational and financial workflow
Coverage verification alone may not address acquisition cost, sourcing, reimbursement lag, patient cost sharing, claim adjustment risk, infusion capacity, wastage, or site-of-care requirements.
5. Avoid guarantees and use current authoritative sources
Coverage policies, formularies, reimbursement rates, plan networks, and patient costs can change. Use current payer, CMS, Medicare Administrative Contractor, plan, and program resources. Do not guarantee coverage, approval, reimbursement, coding outcomes, or patient cost.
6. Protect privacy and remain within role boundaries
Do not share protected health information in public forums or unsecured communications. Access professionals should educate and support appropriate healthcare-office stakeholders within approved role, company, legal, and compliance parameters.
The takeaway: Medicare complexity is increasing the importance of access expertise
Rising spending, growing managed-care enrollment, concentrated beneficiary complexity, evolving drug benefit design, and provider financial pressure make accurate, current, and compliant access support increasingly important.