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Lauren Flynn Kelly

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Radar On Market Access: PhRMA, Conservatives Criticize Pelosi Drug Pricing Legislation

Posted by Lauren Flynn Kelly on Oct 10, 2019

Although there is bipartisan support for drug pricing reform and recent bills introduced in the House and the Senate share some concepts, conservatives and pharmaceutical manufacturers have found plenty to dislike about the drug pricing legislation unveiled in September by House Speaker Nancy Pelosi (D-Calif.), AIS Health reported.

In addition to restructuring the Part D benefit to include an out-of-pocket cap, the Lower Drug Costs Now Act (H.R. 3) would allow the HHS secretary to negotiate drug prices for at least 250 drugs where there is no effective competition. Manufacturers would be subject to certain transparency requirements and a "noncompliance fee." Moreover, the bill would require that the negotiated price should be no more than 1.2 times the weighted average of the price in six other countries.
 
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Topics: Industry Trends, Provider, Payer

Radar On Market Access: CMS Projects Record-High Medicare Advantage Enrollment in 2020

Posted by Lauren Flynn Kelly on Oct 8, 2019

2020 is shaping up to be another competitive year for the Medicare Advantage program, which will feature an additional 600 plan choices and a continued decline in the average monthly premium, AIS Health reported. With its annual release of the so-called landscape files for the MA and Part D programs, CMS on Sept. 24 said it expects MA enrollment to reach an all-time high of 24.4 million in 2020, up 10% from the current enrollment of 22.2 million.

For 2020, the average monthly MA plan premium will drop by 14% to an estimated $23, the lowest average monthly premium since 2007. As the Affordable Care Act health insurer fee (HIF) returns in 2020, CMS's bullish enrollment outlook "indicates most plans are prioritizing stability of benefits and enrollment," observed securities analyst Michael Newshel in a Sept. 24 research note from Evercore ISI.
 
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Topics: Industry Trends, Data & Analytics, Provider, Payer

Radar On Market Access: Industry Groups Praise OIG Report on Medicare Part D Rebates

Posted by Lauren Flynn Kelly on Sep 26, 2019

Industry trade groups that would like rebates preserved in the Medicare Part D purchasing system were thrilled to see a Sept. 13 report from the HHS Office of Inspector General that they viewed as dispelling the oft-purported "myth" that rebates are responsible for high drug prices, AIS Health reported.

The report examining the more than 1,510 brand-name drugs with Part D reimbursement and rebates between 2011 and 2015 found that rebates did not always go up when unit reimbursement grew.
 
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Topics: Industry Trends, Data & Analytics, Provider, Payer

Perspectives on Electronic Real-Time Benefit Tool

Posted by Lauren Flynn Kelly on Aug 8, 2019

CMS in a final Medicare Advantage and Part D drug pricing rule posted in May finalized the requirement that Part D sponsors implement an electronic Real-Time Benefit Tool (RTBT). While the tool offers the potential to accelerate electronic prescribing, improve formulary adherence and lower prescription drug spending, it may pose a heavy information technology burden for some plans and require effort on the part of plans to encourage prescriber adoption, AIS Health reported.

According to the rule, each Part D sponsor must implement at least one RTBT capable of integrating with at least one prescriber's e-prescribing system or electronic health record (EHR) to "provide prescribers who care for its enrollees complete, accurate, timely and clinically appropriate patient-specific real-time formulary and benefit (F&B) information (including cost, formulary alternative and utilization management requirements)" by Jan. 1, 2021.
 
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Topics: Industry Trends, Provider, Payer

Radar On Market Access: Post-Rebate Rule, Trump Administration Mulls 'Any and All Tools'

Posted by Lauren Flynn Kelly on Jul 25, 2019

With only six months to go until a planned implementation date of Jan. 1, 2020, HHS on July 11 pulled its controversial rule that would have eliminated pharmaceutical manufacturer rebates in Medicare and Medicaid, leaving Part D stakeholders to ponder the Trump administration's next moves on lowering prescription drug pricing.

Although news of its withdrawal appeared to surprise the investment community, the rebate rule had too much stacked against it to become final, Larry Kocot, a principal at KPMG, LLP, tells AIS Health. "[T]here were a lot of challenges," starting with the Congressional Budget Office's (CBO) estimate that the rule as proposed would have increased federal spending by about $177 billion over the next decade.
 
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Topics: Industry Trends, Provider, Payer

Radar On Market Access: CMS Requires Part D Plans to Offer RTBT

Posted by Lauren Flynn Kelly on Jun 27, 2019

CMS in a final Medicare Advantage and Part D drug pricing rule posted last month may have notably walked back proposals around "protected" drug classes and pharmacy price concessions, but the agency finalized the requirement that Part D sponsors implement an electronic Real-Time Benefit Tool (RTBT). While the tool offers the potential to accelerate electronic prescribing, improve formulary adherence and lower prescription drug spending, it may pose a heavy information technology burden for some plans and require effort on the part of plans to encourage prescriber adoption, AIS Health reported.

According to the rule, each Part D sponsor must implement at least one RTBT capable of integrating with at least one prescriber's e-prescribing system or electronic health record (EHR) to "provide prescribers who care for its enrollees complete, accurate, timely and clinically appropriate patient-specific real-time formulary and benefit (F&B) information (including cost, formulary alternative and utilization management requirements)" by Jan. 1, 2021.
 
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Topics: Industry Trends, Provider, Payer

Radar On Market Access: Outstanding Part D Proposals Created Uncertainty in 2020 Bid Process

Posted by Lauren Flynn Kelly on Jun 13, 2019

Medicare Advantage and Part D plan sponsors submitting bids for the 2020 plan year faced a considerable amount of uncertainty compared with recent years. On the Part D side, there was "not only one but two pending regulations — both of which would have had a significant impact on bids — and it was difficult for carriers to know 1) how they should bid and 2) how others might be bidding," Shelly Brandel, a principal and consulting actuary in the Milwaukee office of Milliman, tells AIS Health.

Perhaps creating the most uncertainty was when HHS would finalize a January proposed rule that would eliminate safe-harbor protections for rebates paid by manufacturers to plan sponsors under Medicare Part D and Medicaid. CMS in Part D bidding guidance posted May 20 confirmed what it had hinted at in an April memo on how bids should be prepared: the rule would not be finalized before the June 3 bid deadline.
 
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Topics: Industry Trends, Provider, Payer

Radar On Market Access: CMS Extends Options to States to Test Innovative Dual-Eligible Care Models

Posted by Lauren Flynn Kelly on May 9, 2019

Although independent evaluations of ongoing demonstrations to integrate care for dual-eligible Medicare-Medicaid beneficiaries are still underway, an April 24 letter from CMS Administrator Seema Verma signaled the agency's commitment to proving the value of the models as well as testing alternatives, AIS Health reported.

In the letter to state Medicaid directors, CMS extended three new opportunities to "test state-driven approaches" for integrating duals' care:
 
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Topics: Industry Trends, Provider, Payer

Perspectives on New MA Rule That Touches Protected Classes

Posted by Lauren Flynn Kelly on Jan 24, 2019

CMS on Nov. 26, 2018 issued a proposed rule making changes to the Medicare Advantage and Part D programs that would take effect in 2020. Key provisions in CMS’s latest drug pricing rule include a proposal to extend new flexibility to plan sponsors in the area of so-called six "protected" drug classes and the required implementation of a new electronic real-time benefit tool (RTBT), AIS Health reported.

Under CMS's Contract Year 2020 Medicare Advantage and Part D Drug Pricing Proposed Rule, plans would be able to:
 
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Topics: Industry Trends, Provider, Payer

Radar On Market Access: New MA Rule Touches Protected Classes, Imposes Pricing Tool

Posted by Lauren Flynn Kelly on Dec 13, 2018

CMS on Nov. 26 issued a proposed rule making changes to the Medicare Advantage and Part D programs that would take effect in 2020. Key provisions in CMS’s latest drug pricing rule include a proposal to extend new flexibility to plan sponsors in the area of so-called six "protected" drug classes and the required implementation of a new electronic real-time benefit tool (RTBT), AIS Health reported.

Under CMS's Contract Year 2020 Medicare Advantage and Part D Drug Pricing Proposed Rule, plans would be able to:
 
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Topics: Industry Trends, Provider, Payer