Tag: accountable care organizations

Massachusetts Releases PBM Transparency Report

Posted on June 6, 2019 by - Government Affairs

The Massachusetts Health Policy Commission has released its analysis of state PBM activity titled, Cracking Open the Black Box of Pharmacy Benefit Managers. Notably, the report concludes the need for additional PBM oversight and scrutinized the practice of PBM spread pricing.

According to the report, PBM spread pricing practices appear to be increasing in Massachusetts: “…this practice covered 22% of PBM compensation in 2014, but rose to 54% in 2016. This practice, often used as a means of payment for PBM services instead of administrative fees, may have significant impacts on public insurance programs, employer health plans, and consumers. Additionally, the media has reported growing concerns from pharmacists about low reimbursement rates from PBMs in Massachusetts and other states. PBM payments to pharmacies are sometimes even below the pharmacy’s acquisition costs of the drugs, which can affect the financial viability of pharmacies and potentially impact access to care. Yet the extent to which PBMs profit from this practice, and on which drugs, remains largely hidden from payers and the public.”

Additionally, the Commission cited, “As part of the fiscal year 2020 state budget strategy on MassHealth drug prices, the Baker-Polito administration proposed a new requirement for PBMs to be transparent about their pricing and to limit PBM margins under contracts with MCOs and accountable care organizations (ACOs), which the administration projects will save $10 million. To advance transparency, MassHealth recently released a bulletin directing MCOs and MassHealth Accountable Care Partnership Plans to obtain and submit to MassHealth drug-specific data from their PBMs including payments to dispensing pharmacies and rebate and administrative payment data.”

Based on recent activities and discussions with Massachusetts, additional PBM policies are forthcoming. Frier Levitt Government Affairs’ (FLGA) forecasting and monitoring services help keep healthcare and life sciences stakeholders “in the know” regarding pending policy and marketplace changes. Forecasting and monitoring helps stakeholders make better strategic decisions so that they no longer just “reacting” to outside changes. Contact FLGA today for forecasting and monitoring services tailored for you and your organization.

CMS Makes Proposed Copay Accumulator Rule Final

Posted on April 30, 2019 by - Government Affairs

In January 2019, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule titled, “Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2020,” targeting Accountable Care Organizations (ACOs), payers and Affordable Care Act (ACA) exchange stakeholders, with one component of the proposed rule focusing on copay accumulators. CMS has now finalized this proposed rule, allowing payers to implement copay accumulator programs to prevent the application of manufacturer coupons from applying to patient out of pocket costs.

Currently, copay accumulators are being implemented by insurance companies and Pharmacy Benefit Managers (PBMs), harming patient access. With this payor program, the value of copay assistance cards/coupons issued by manufacturers do not count towards out-of-pocket costs that are applied toward deductibles. The result has caused a cost shift onto consumers and away from employers and payers. Unfortunately, in the proposed rule, the Administration defends the use of copay accumulators.

In contrast, Arizona, Virginia, and West Virginia are leading the state legislative efforts this year to ban copay accumulator programs, although Arizona’s approach to this issue is much more measured.

CMS has stated that its final rule would apply to individual market, small, and large group and self-insured group health plans starting in 2020. The final rule is effective June 25, 2019 which will be sixty days from its April 25, 2019 publication date. There will be no further public comments taken for this rule.

States are currently trending against CMS’ position regarding copay accumulators. If you would like to target your state legislation, Frier Levitt Government Affairs (FLGA) can lobby state legislators to prohibit copay accumulator programs. Contact FLGA today to get started.

ONC and CMS Introduce Proposed Rules on Target Data Blocking

Posted on March 12, 2019 by - Government Affairs

Both the Office of the National Coordinator for Health Information Technology (ONC) and the Centers for Medicare and Medicaid Services (CMS) have introduced proposed rules on Target Data Blocking, which, if properly tailored and modified, have the potential to substantially impact Accountable Care Organizations (ACOs), Independent Physician Associations (IPAs), Clinically Integrated Networks (CINs) and other value-based care organizations (VBCOs) by greatly expanding data transparency as between payers, including Medicare Advantage Organizations (MAOs), and VBCOs.

The CMS proposed rule on target data blocking is designed to transition the industry towards interoperability, and further builds upon CMS’ goals, deriving from the 21st Century Cures Act and Executive Order 13813, to improve access to, and the quality of, information that Americans need to make informed health care decisions, including data about health care prices and outcomes, while minimizing reporting burdens on affected plans, health care providers, or payers.

According to the ONC, their proposed rule on target data blocking would implement certain provisions of the 21st Century Cures Act, including more fully and completely describing the conditions and maintenance of certification requirements for health information technology (health IT) developers under the ONC Health IT Certification Program (Program), the voluntary certification of health IT for use by pediatric health care providers, and by insulating certain reasonable and necessary IT activities that do not constitute information blocking. The implementation of these provisions would advance interoperability and support the access, exchange, and use of electronic health information. The proposed rule would also modify the 2015 Edition health IT certification criteria and Program in additional ways to advance interoperability, enhance health IT certification, and reduce burden and costs.

Why You Should Participate:

For VBCOs, expansion and clarification of the 21st Century Cures Act prohibition on “information blocking” presents a rare opportunity to create a more level playing field as between VBCOs and payers by forcing the enhancement of payer data transparency, which is critical for VBCOs to gather and/or review the data and methodologies held/employed by payers to calculate patient risk scores and to confirm the accuracy of payer-calculated accrued shared savings (or shared risk). Additionally, VBCOs, being in the unique position of having comprehensive in-house data analytics departments and proprietary healthcare data analytics methodologies or software, must be certain that the new Health IT requirements imposed by the proposed rulemakings are both clear and reasonably implementable from both a cost and technological standpoint.

Submitting targeted, concise comments to CMS and ONC expressing questions and concerns relevant to the above issues is one means of ensuring your company’s continued success in the fast-changing value-based care landscape. Indeed, even if the agencies disagree with a proposed suggestions for improving the rules, in so doing, they will have to provide reasons therefor, thereby providing you with invaluable advanced guidance for full compliance with the rules prior to their implementation.

There are multiple ways to respond to the ONC’s “21st Century Cures Act: Interoperability, Information Blocking and the ONC Health IT Certification Program” and/or CMS’ “Medicare and Medicaid Programs; Patient Protection and Affordable Care Act; Interoperability and Patient Access for Medicare Advantage Organization and Medicaid Managed Care Plans, State Medicaid Agencies, CHIP Agencies and CHIP Managed Care Entities, Issuers of Qualified Health Plans in the Federally-facilitated Exchanges and Health Care Providers” proposed rules. Contact Frier Levitt Government Affairs to have your voice heard.