At the end of last year there was a significant switch for home infusion from AWP to ASP + 6 in Medicare Part B. This switch happened through the Cures Act which also created a mechanism for a special home infusion service payment. In order to pay for this new payment, CMS urged Congress to change the AWP payment for home infusion drugs to the industry standard of ASP +6. Doing so created smaller payments for home infusion and the switch was effective in 2017. The service payment will not be in effect until 2021. There is legislation currently in Congress that addresses the gap before the service payment is effective.
The House of Representatives has passed the Medicare Part B Improvement Act of 2017 (H.R. 3178) which would create a temporary transitional payment, beginning January 1, 2019, for services related to Medicare Part B Durable Medical Equipment (DME) infusion drugs before a permanent payment structure, that was part of the 21st Century Cures Act, is finalized in 2021. The bill is currently in the Senate.
H.R. 3163, introduced by Health Subcommittee Chairman Pat Tiberi (R-OH) and Rep. Bill Pascrell (D-NJ), creates a transition payment for home infusion therapies for Medicare beneficiaries to ensure there is no gap in care.
It is not clear when this legislation will take the next step forward. CMS may lag behind the 2021 deadline in creating regulations for the service payment. Additionally, Congress may be preoccupied with the debt ceiling debate that could further delay the legislation. If you have questions, contact us today.
The Commission on Combating Drug Addiction and the Opioid Crisis has released their recommendations. In their first briefing, they urged President Trump to declare a national public health emergency. The committee created an alarming visual of opioid related deaths, stating 142 Americans die each day which is like having the death toll of September 11th every three weeks.
From 2000-2015 there were over 500,000 drug related deaths with opioids leading in the drug of choice. “The average American would likely be shocked to know that drug overdoses now kill more people than gun homicides and car crashes combined,” the commission reported.
One of the goals of declaring a public emergency would be to create a sense of urgency in not only the government and public but also the health care field. In addition, if an emergency is declared, HIPPA regulations would temporarily relax in order to collect additional data which could lead to further information on opioid trends, user demographics, and ways to help fight the crisis.
The emergency would also allow the government to waive regulation that limits the number of Medicaid and Medicare recipients who can receive residential treatment for their addiction with an additional measure to expand access to medication that helps treat opioid addiction, such as naloxone which is used to reverse overdoses.
The Commission suggested funds for the emergency could be available by enacting the Stafford Disaster Relief and Emergency Assistance Act or the Public Health Service Act, with approximately $1.2 million available through the Disaster Relief Fund and $57,00 from the Public Health Emergency Fund. Whether these assets would be enough to create an impact on opioid abuse would remain to be seen.
The Affordable Care Act (ACA) has expanded treatment to Americans and with Trump adamantly against the ACA and the Better Care Reconciliation Act (BCRA) uncertain there is cause for concern. An emergency was declared on August 10th by Trump. It will provide avenues for treatment but also create further questions regarding health insurance coverage for those in the private sector and those not covered by Medicaid or Medicare. Regardless, the administration will still need to tackle the issue of treatment coverage, something that has been and continues to be an ongoing issue. For more information, contact us today.
We are pleased to announce our new August 22nd 2-3 EST webinar through the Accreditation Commission for Health Care (ACHC) titled Retail to Specialty: How Legislative and Regulatory Issues Affect Drug Reimbursement.
As the prescription drug market becomes more sophisticated, patients, PhRMA and payers will rely more on the expertise of a community pharmacist. Consequently, the pharmacists must also continue to evolve in order to remain competitive and service biological products as well as be familiar with a rapidly changing reimbursement environment. Participants will learn the following in this presentation:
Discover what is happening in the specialty drug market
Learn how payers are reimbursing pharmacies that are expanding to serve specialty patients
Become familiar with the necessary accreditation
Learn suggestions about what disease states to start with
Understand the current state and federal policies surrounding specialty medications
The following is an excerpt from our cover story printed in Specialty Pharmacy Times. Republished with persmission.
Co-Written by Ron Lanton, III, ESQ, Frier Levitt Government Affairs, and Victor Morrison, Next IT Healthcare
July 28, 2017
WHAT IF YOU AWOKE TO THIS HEADLINE? “Amazon Acquires Specialty Pharmacy”
Graduate pharmacy class: circa 2030.
“Good morning, class! Today, we will be doing a case study on specialty pharmacies, starting with their early success introducing a disruptive new service model to accommodate the influx of biologics in the 1990s and early 2000s and then moving on to how, like Kodak, Blockbuster Video, and countless others, they didn’t recognize the implications of emerging digital technologies and were made obsolete by 2025. Let’s get started. Alexa, please project case study 124 onto the center screen.”
This scenario is real, and other industries offer many examples of the dire consequences of digital disruption. With shrinking margins, a dated focus on incremental platform improvements, the increasing desire of consumers for digital self-service, and heavy strategic reliance on human resource–dependent call centers, specialty pharmacies are facing significant and likely fatal disruptions as they enter the crosshairs of technology.
Clinging to a strategy that dictates that high-touch models are the only way to remain viable, most specialty pharmacies have no strategic clarity to support the critical move to digital and mobile health (mHealth) engagement.
A quick survey of the current specialty pharmacy digital landscape indicates that most websites are still glorified business cards and mHealth is the elephant in the room, getting little more than lip service. With a glaring lack of digital engagement options for consumers, specialty pharmacies are still spending significant organizational energy utilizing unscalable call center resources to chase down patients for onboarding, adherence interventions, refills, etc.
Enter Amazon, the most technologically advanced, consumer-centric digital retail distribution organization in the world. With Amazon, you have an entity in prime (pun intended) position to disrupt the specialty and/or retail pharmacy industry.
How difficult would it be for Amazon to buy a small specialty pharmacy licensed in all 50 states and leverage their advanced distribution system and consumer relationship platforms to create an unprecedented ability to deliver specialty pharmacy services and therapies at scale?
Their Alexa, Echo, and Dot conversational user interfaces, synchronized with their ubiquitous Kindle smart devices, could very effectively engage patients, answer questions 24/7, enable the collection of real-time clinical insights, and drive adherence/refills with real-time interventions.
With traditional call center costs dramatically reduced by Amazon’s ability to deliver a pervasive front-end engagement channel for millions of patient relationships by using technology, the ability to compete for payer contracts and deliver more lucrative pharma services at a lower cost would be unprecedented.
By disrupting the current limited-scale high-touch model with an infinitely scalable smart-touch technology-dependent model, Amazon could leverage remote-monintoring devices, artificial intelligence-powered conversational user interfaces, behavior-based real-time virtual coaching, and a low-cost optimized call center to deliver personalized and holistic daily engagement at any point during the patient’s clinical journey at an extremely low price point.
The smart touch approach would trigger a transformative move from traditional call centers that support adherence to a monthly therapy to an unlimited digital engagement platform that will uncover unprecedented real-time data insights and enable optimized adherence to the right therapy.