- Trump wants broader role for telehealth services in Medicare (apnews.com)
The Trump administration is taking steps to give telehealth a broader role under Medicare, with an executive order that serves as a call for Congress to make doctor visits via personal technology a permanent fixture of the program...The order President Donald Trump signed...applies to one segment of Medicare recipients — people living in rural communities. But administration officials said it’s intended as a signal to Congress that Trump is ready to back significant legislation that would permanently open up telehealth as an option for all people with Medicare...READ MORE
- How Hospitals and PBMs Profit—and Patients Lose—From 340B Contract Pharmacies (drugchannels.net)
The stunning growth of specialty pharmacies in the 340B Drug Pricing Program has accelerated a troubling trend: Patients covered by commercial insurance and Medicare Part D are footing the bill for 340B savings...That's the uncomfortable reality of the 340B program’s hidden prescription economics...Whenever a prescription is eligible for 340B pricing, an insured patient could pay thousands of dollars out of pocket—even as the 340B hospital and its contract pharmacy generate substantial profits. Meanwhile, private health plans and Medicare pay full price for drugs that are sold to 340B covered entities at deep discounts, further subsidizing hospitals and PBM-owned specialty pharmacies...340B Health, which lobbies for hospitals that participate in the 340B Drug Pricing Program, argues that the program “does not cost taxpayers any money.” Be wary of this misleading half-truth. The harsh reality is that patients and payers are funding the savings that flow back to 340B covered entities and their contract pharmacies...This fundamental unfairness is discussed rarely if ever. Rather than touting how hospitals spend their 340B savings, it’s time to start asking where those savings come from...READ MORE
- CMS Lowers Medicare Insulin Copays (drugtopics.com)Out-of-Pocket Insulin Costs Remain Stable for the Privately Insured (ajmc.com)
The Centers for Medicare & Medicaid Services is reducing insulin copays for seniors who are eligible for Medicare via an executive order from President Donald Trump...Participating enhanced Medicare Part D plans in 2021 will provide a broad set of insulins at a maximum $35 copay for a month’s supply of each type of insulin, the White House said in a fact sheet on the new initiative...CMS estimates that beneficiaries could save $446, or 66%, a year for their insulins, the agency said in a press release...READ MORE
- Novartis forced to face claims it fired employee for raising Gilenya kickback scheme concerns (fiercepharma.com)
Dogged by whistleblower kickback claims over its multiple sclerosis med Gilenya for years, Novartis has run off a recent string of court wins to escape the allegations...But in one New Jersey suit, Novartis will now be forced to confront a former employee's claims that he was fired without cause for bringing a kickback scheme to light...Novartis must face claims it retaliated against one of its employees for raising concerns the drugmaker engaged in a pharmacy benefit manager kickback scheme...former Novartis employee Joseph Perri alleged he was terminated after notifying management about "disparities" between the drugmaker's commercial and Medicare Part D rebates paid to a PBM for Gilenya...READ MORE
- Some providers face daunting repayment deadline for Medicare advance loans (fiercehealthcare.com)
Hospital groups are imploring either the Centers for Medicare & Medicaid Services or Congress to step in and help providers facing loan repayments happening as soon as Aug. 1...The...deadline has sparked concerns from some experts and hospital groups that worry providers couldn’t afford to lose out on Medicare revenue as they combat revenue losses caused by the pandemic. While the program was intended to be a short-term solution, COVID-19 surges are proving that is not the case for some hospitals...At the onset of the pandemic in March, the Centers for Medicare & Medicaid Services extended the advance payment program, which has been used previously to help providers beset by disasters...CMS had given out $100 billion of loans before suspending the program...The goal behind the program is to help providers stay afloat and was meant to be a short-term solution, as repayment starts 120 days after a provider gets the first payment...READ MORE
- Insurers worry drug companies could game changes to Medicaid rebate program in new rule (fiercehealthcare.com)
Insurers are worried a raft of proposed changes to the Medicaid Drug Rebate Program could lead to drug manufacturers gaming the system to charge higher prices...Several insurer groups commented on the proposed rule that the Centers for Medicare & Medicaid Services released last month to get states and drugmakers to create more value-based payment arrangements...If finalized, the rule would relax some of the requirements for the average manufacturer price and best price that manufacturers must provide for Medicaid. Under the new rule, a manufacturer could report multiple best prices for a therapy under the Medicaid Drug Rebate Program, but any best price has to be tied to a value-based purchasing agreement...READ MORE
- Copay Maximizers Are Displacing Accumulators—But CMS Ignores How Payers Leverage Patient Support (drugchannels.net)
Last week, the Centers for Medicare and Medicaid Services released its final Notice of Benefit and Payment Parameters for the 2021 benefit year...This final rule permits insurers to exclude the value of a pharmaceutical manufacturer’s copay support program from a patient’s annual deductible and out-of-pocket maximum obligations...Translation: CMS has confirmed that insurers have the option to use copay accumulator adjustment for their pharmacy benefit programs...Patients on specialty drugs lose big from accumulators, while plans profit from the lower spending that results. Consequently, copay maximizers have emerged as a more patient-friendly alternative to accumulators...Plan sponsors are publicly denouncing copay support programs—while they’re privately embracing them. CMS’s final rule ignores the troubling reality behind maximizers and accumulators: They encourage plans to use pharmacy benefit deductibles as a scheme that allows payers—not patients—to reap the greatest benefits from a manufacturer’s patient support program...READ MORE
- Pharmacy groups tell HHS that any action on rebate rule must involve fixing pharmacy DIR fees (chaindrugreview.com)
The country’s leading pharmacy groups said that any action on a prescription drug rebate rule must address skyrocketing fees extracted by pharmacy benefit managers on behalf of plan sponsors in Medicare Part D...“We remind the Administration of the continuous and heightened impact of pharmacy DIR fees imposed by Medicare Part D plan sponsors and their pharmacy benefit managers (PBMs) on our members. Pharmacy DIR fees are growing beyond CMS’ projection of 10% year-over-year...“If pharmacy DIR fees are not addressed in a forthcoming rebate rule, the impact on our members and their ability to care for patients in such a system will prove detrimental...READ MORE
- Pfizer sues to cut Vyndaqel copays, calling Medicare ban unconstitutional (fiercepharma.com)
Pfizer’s rare heart disease med Vyndaqel, at $225,000 a year, is too pricey for many patients. To help Medicare participants afford the expensive drug—and maintain its hefty sticker price—the Big Pharma is going as far as to argue the U.S. government’s anti-kickback policy is unconstitutional...Pfizer questions two federal regulations that prohibit drugmakers from offering direct payments to help cover a drug’s cost or working with charity programs to direct their funding—and Medicare patients—to a particular medicine...If Pfizer's argument succeeds, essentially, it would open up federal insurance programs to the sort of copay assistance drugmakers often offer to privately insured patients, particularly for pricey medications and new launches...READ MORE
- HHS files appeal to reinstate controversial MA overpayment rule (fiercehealthcare.com)
The Department of Health and Human Services has filed an appeal to reinstate a key rule that handles overpayments to Medicare Advantage plans, arguing a lower court's ruling was based on a flawed premise...The appeal, filed Thursday in the federal Court of Appeals for the District of Columbia Circuit, could decide how much money MA plans, an increasingly lucrative market for insurers, will have to give back to Medicare for diagnosis errors. HHS argues that an earlier ruling striking down the plan misunderstood how Medicare audits MA plans...The appeal is the latest salvo in a legal fight with insurers over a 2014 rule proposed by the Centers for Medicare & Medicaid Services...READ MORE