HealthCare Roundtable e-News – July 30, 2018

Physician Groups Propose Tweaking MIPS and House Hearing

In a hearing before the House’ Energy and Commerce committee’s health subcommittee last week, physician groups testified and recommended changes to MACRA, the Medicare Access and CHIP Reauthorization Act of 2015. The witnesses claimed that MIPS, the act’s Merit-based Incentive Payment System, is “far from perfect” and requires a second look.

The payment system, which rewards or penalizes doctors based on performance, is currently on track to fall short of its goals, due to opt-outs and low incentive payments for good performance. Kurt Ransohoff, board chairman of America’s Physicians Groups, claimed that too many doctors are exempt from MIPS, and the low-volume threshold, which determines whether a doctor must participate in the program, should be reduced.

“This level of exemptions undermines the spirit of the law and impedes the goal of moving our nation’s health care system to value,” claimed Ransohoff.

Some have expressed that alternative pay models should be considered by CMS, particularly those recommended by Physician-Focused Payment Technical Advisory Committee. However, David Barbe, the immediate past president of the American Medical Association, has claimed that CMS has shown little interest in considering any of the recommended models.

Verma Presses Part D Plans to Push Generics as High-Cost Brand Alternatives

In response to a tweet from Health and Human Services Secretary Alex Azar asking CMS to examine how Part D plans could be doing more to push low-cost generics, CMS released a memo illustrating methods Part D plans can implement to push generics as alternatives to higher-cost brands. CMS chief Seema Verma followed up with the memo and, in a tweet, responded to Azar.

“We’ve taken action. Today, @CMSGov issued a memo to Part D plans explaining the tools available & the expectation CMS has to ensure beneficiaries don’t unnecessarily pay for high-cost branded products, when low-cost generics are available on formulary. Stay tuned for more on this,” tweeted Verma.

The memo outlines several ways in which plans can approach generics in practice, explaining that if a Part D enrollee wishes to obtain a prescription for a non-formulary brand-name drug or a high-tier drug when an equivalent generic is on the formulary, the prescriber must provide the plan sponsor a timely a statement complying with exception criteria laid out in the memo. In addition, the memo states that if the supporting statement is absent, the plan should deny the request for lack of medical necessity.

The generic lobby has expressed concerns that current prices for generics are threatening to be unsustainably low. Because of this, the Association for Accessible Medicines (AAM) is urging the Trump administration to end inflation-based penalties for generic drugs in Medicaid, and to reconsider how generic injectable drugs are paid for in Medicare Part B.

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Gag-Clause Ban Passes Senate Committee with Biosimilar Pay-For-Delay Measure

A Senate committee unanimously approved legislation on Wednesday, July 25th, that would ban gag clauses preventing pharmacist disclosure of drug prices in exchange for private insurance plans. In addition, the bill includes provisions to grant the FTC more visibility into biosimilar pay-for-delay agreements.

Known has the Patient Right to Know Drug Prices Act, pharmacists may disclose to a consumer when it is cheaper to buy a drug out of pocket than through their insurance. The bill includes provisions that allow the defining of out-of-pocket costs “to prevent companies from using clever contracting to get around the gag clause prohibition,” bill sponsor Sen. Susan Collins (R-ME) said during Wednesday’s markup.

The Patient Right to Know Drug Prices Act currently only applies to exchange and private plans. However, Collins has also introduced the Know the Lowest Price Act, which would ban the practice in Medicare Part D and aid CMS’ efforts in removing gag clauses from Part D plans.

Additionally, Rep. John Sarbanes (D-MD), introduced the Biosimilars Competition Act of 2018 on Monday, July 23rd, which the Roundtable has expressed support for, and advocates for the same filings.

Last March, the Pharmaceutical Care Management Association released a statement saying it supports pharmacies being able to share the cash price, but “to the degree this issue was ever rooted in more than anecdotal information, it has been addressed in the marketplace.”

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Democrats Claim Health Package on House Floor ‘Goes in the Wrong Direction’

In opposition to the collection of health bills set to be reviewed by the House last week, Democrats argued that the health package being considered failed to address measures aiming to aid lowering coverage premiums. The bills being voted on, which include a delay the ACA’s insurance tax and the allowance of all exchange consumers to purchase less-generous “catastrophic” health plans, has many Democrats claiming the package goes in the wrong direction.

“These bills do nothing to roll back the premium increases caused by the Republican tax bill, the Administration’s relentless sabotage campaign, and the uncertainty in the markets caused by Republicans’ repeated efforts at repeal,” claimed Leslie Dach, chair of the pro-ACA group Protect Our Care. Dach adds that the display shows the GOP to only be interested in “giving themselves political cover before they face their constituents this fall.”

In its recent study, the Center for American Progress reported its findings that individuals will pay an average $970 a year more for coverage due to separate Trump administration and GOP policies, including the repeal of the individual mandate and introduction of non-ACA compliant plans.

The study also claims that insurers’ rate filings for 2019, “have made it clear that the administration’s backing of substandard coverage options and elimination of the individual mandate are driving up premiums for consumers.”

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