- Pharmacy “DIR fee” loophole must close, NACDS RxIMPACT urges (chaindrugreview.com)
The National Association of Chain Drug Stores RxIMPACT program has launched an Action Alert, urging Congress to provide “DIR fee” relief in time to save pharmacies and to reduce seniors’ out-of-pocket drug costs...pharmacy advocates are contacting U.S. Senators and members of the U.S. House of Representatives to build support for the Phair Pricing Act (H.R. 1034/S. 640). The bill would do what a recent Medicare rule left undone: providing relief from abusive pharmacy direct and indirect remuneration fees. The goal is to assure this is part of a drug-pricing bill that is enacted soon...“If our government is serious about stopping this unacceptable treatment of pharmacies, about reducing patients’ drug costs at the pharmacy counter, and about reducing overall healthcare costs, then they need to close this loophole and end the abuses of pharmacy DIR fees now,” said NACDS president and chief executive officer Steven Anderson...READ MORE
- Lawmakers hear bill to require tourist-focused microhospital to accept Medicare, Medicaid (thenevadaindependent.com)
Elite Medical Center...Since it opened...its business model has been based on providing emergency care to tourists...The federally-run Medicare program for the elderly and the state-run Medicaid program for low-income residents just isn’t lucrative and therefore isn’t part of its business model...The rest of Nevada’s hospitals use their privately insured patients to subsidize the cost of treating those covered under Medicare and Medicaid. Hospitals argue that the rates paid by government insurance programs don’t come close to the actual costs of providing care, so they must carefully balance the number of patients they take under each type of insurance in order to stay financially solvent....the other hospitals believe that Elite is siphoning off the well-insured patients at their expense and without shouldering any of the burden for treating those on Medicare or Medicaid. That’s why the state hospital association is pushing for lawmakers to pass AB232, which would require essentially all Nevada hospitals to accept Medicare and Medicaid...READ MORE
- CMS unveils CAR-T proposal, with emphasis on patient outcomes (biopharmadive.com)
Under a proposal...Medicare would cover CAR-T cell therapies through a Centers for Medicare and Medicaid Services pathway known as Coverage with Evidence Development...The proposal holds a mix of provisions, including that patients must be monitored for at least two years post-treatment. Hospitals administering CAR-T therapy, whether through inpatient or outpatient care, must participate in a CMS-approved registry that collects data on patient outcomes and characteristics and then compares that data to what's been seen in pivotal clinical trials of the therapy or standard of care treatment...Hospitals and clinicians would track certain clinical data elements at baseline, at treatment, and then at three-month, six-month, one-year and two-year follow ups following administration...
- EDITORIAL: When the government can’t afford health care (reviewjournal.com)
If you want a glimpse of how single-payer health care would work, look at what’s happening to Sunrise Hospital and Medical Center...As the Review-Journal’s Jessie Bekker reported Wednesday, 70 percent of the families who use Sunrise’s neonatal intensive care unit are on Medicaid. Sunrise CEO Todd Sklamberg says that Medicaid pays the hospital a flat daily rate of $1,487 per baby. That’s around one-tenth of Sunrise’s average daily charge of $14,815...Mr. Sklamberg said the hospital’s deficit for uncompensated infant care was $77 million last year. If the Legislature doesn’t increase Medicaid reimbursement rates this session, he said, Sunrise will consider reducing NICU services for all patients. The hospital, he said, is on an “unsustainable trajectory.”...This is the aspect of single-payer health care that Bernie Sanders doesn’t talk about...
- Opinion: Big Storm Brewing for American Specialty Pharmacies and Patients (drugtopics.com)
Specialty pharmacies dispense some of the most expensive, sensitive, and life-saving medications to patients, the kinds of medications that can cost more than $100,000 a year. Unfortunately, the way these prescriptions are being filled today is often chaotic and ripe for fraud, is different in each state, and potentially is about to get even worse for patients...When new prescriptions come in to these pharmacies, they go through what is often a very slow prescriber credential verification process that can involve manually calling or looking up licenses for the prescribing physicians on various board websites. When refills arrive, the pharmacies usually don’t verify prescriber licenses at all. The prescriber’s license could have expired, or the physician moved to a new state, had their license revoked, retired, or passed away...This means that patients are sometimes getting drugs from unlicensed prescribers or are being kept waiting for medications because of slow manual verification. It’s a process that lets through a lot of fraud and abuse...READ MORE
- NACDS, NCPA brief Congressional Doctors Caucus on DIR fee reform (chaindrugreview.com)
NACDS and the National Community Pharmacists Association held a briefing this week for the Congressional Doctors Caucus...chaired by Rep. Phil Roe...comprised of 16 medical providers in Congress who use their medical expertise to develop patient-centered healthcare policy...NACDS and NCPA discussed the Centers for Medicare & Medicaid Services’ recently released proposed rule—Modernizing Part D and Medicare Advantage to Lower Drug Prices and Reduce Out-of-Pocket Expenses—and explained the serious repercussions of direct and indirect remuneration (DIR) fees and the impact they can have on patient access to care and on pharmacies, who are struggling to maintain their businesses amid the uncertainty caused by the retroactive fees. The groups noted that they have advocated strongly for DIR reform in the CMS proposal because it will benefit pharmacies and the patients they serve.
- Emergency room off Las Vegas Strip makes waves with new business model (reviewjournal.com)
Just like any full-service emergency room, Elite Medical Center treats a range of urgent medical problems, from headaches to heart attacks. But unlike at the other ERs in Southern Nevada, you’ll generally pay more for your care...That’s because the facility doesn’t contract with any insurer. So if you break a bone or your child has an earache and you go there, you’ll be paying for out-of-network care...Elite is licensed as a hospital by the state, but experts say it is operating similarly to free-standing emergency rooms that have become common recently in other states. It is the only unaccredited hospital in Clark County that provides emergency care but doesn’t contract with insurers...There’s no license for a free-standing ER in Nevada, though hospitals are allowed to open satellite emergency rooms that provide care at other locations....State law doesn’t mandate that these facilities be accredited by the federal Centers for Medicare or Medicaid Services or accept any insurance, private or public...“We don’t think that’s appropriate,” said Bill Welch, president and CEO of the Nevada Hospital Association, which represents UMC and 65 other medical facilities statewide. “We think that Elite Medical Center, if they want to operate as a hospital in the state, that they should operate as a CMS-certified center and they should be accredited and Medicare-participating. Without those things, we’re concerned.”
- Drugmakers Jazz, Alexion, Lundbeck to pay $123 million to resolve U.S. charity kickback probe (reuters.com)
Three drugmakers will pay $122.6 million to resolve claims they used charities that help cover Medicare patients’ out-of-pocket drug costs as a way to pay kickbacks aimed at encouraging use of their medications, including some expensive ones...The U.S. Justice Department...said Jazz Pharmaceuticals Plc, Lundbeck A/S and Alexion Pharmaceuticals Inc had become the latest companies to settle claims stemming from an industry-wide probe of drugmakers’ financial support of patient assistance charities...The government has alleged in earlier settlements that drugmakers used such charities as a means to improperly pay the copay obligations of Medicare patients using their drugs in violation of the Anti-Kickback Statute...READ MORE
- HHS’s Multi-Pronged Approach To Lower Drug Prices: Will It Work? (forbes.com)
...the Department of Health and Human Services has put forward a series of initiatives aimed at lowering prescription drug prices, Medicare expenditures, and patient cost-sharing. The proposals run the gamut from increasing transparency of net pricing, to allowing the use of certain formulary management tools previously off limits to Medicare plans, to direct price controls...But, will they work? The federal government appears to think so. Several weeks ago, Secretary of HHS Alex Azar stated that "the models being announced create new incentives for plans, patients, and providers to choose drugs with lower list prices...[advancing] our priority of using HHS programs to build a value-driven healthcare system."...it's debatable whether HHS will achieve the twin objectives of lower drug spending and decreased patient cost-sharing as a consequence of implementing its series of initiatives. Some may not get implemented as planned, or not at all given the opposition they evoke. Others may result in tempering the growth in drug costs overall, but raising the amount patients must spend out-of-pocket, whether on premiums or patient cost-sharing...
- Walgreens pays $269.2 million to settle U.S. civil fraud lawsuits (reuters.com)
Walgreens Boots Alliance Inc will pay $269.2 million to settle two whistleblower lawsuits accusing it of civil fraud for overbilling federal healthcare programs over a decade, the U.S. Department of Justice said...The pharmacy chain will pay $209.2 million to resolve claims it improperly billed Medicare, Medicaid and other federal programs from 2006 to 2017 for hundreds of thousands of insulin pens it dispensed to patients it knew did not need them...Walgreens will also pay $60 million to resolve claims it overcharged Medicaid from 2008 to 2017 by failing to disclose and charge the discount drug prices it offered the public through its Prescription Savings Club program...Two pharmacists filed the original complaint concerning the insulin pens in July 2015. A copy of that complaint could not immediately be obtained on Tuesday...Marc Baker, who worked for Walgreens for a decade as a pharmacy manager in Florida, filed the original complaint concerning the drug price discounts in January 2012.