Hi,
I saw my Rheumy today, she told me Congress is trying to lower the clasification of biologics to a lower rating so they will be available in pharmacies, she said that this will make it so insurance companies don’t cover as much cost. Probably the Insurance Companies are greasing somebodies palm to push this through! A group of Rheumatologists are trying to lobby Congress not to do this. She was involved with GRAPPA to come up with treatments for PsA.
Has anyone heard of this?
let me rephrase that, Congress wants to take Biologics out of the “Specialty Pharmacy” status and put it in the general pharmacy, so the Insurance Companies will not have to pay as much of the cost.
I found the source info here:
https://www.rheumatology.org/About-Us/Newsroom/Press-Releases/ID/883/Nine-Physician-Specialty-Groups-Caution-HHS-Against-Proposed-Drug-Pricing-Changes
I’ve worked in the health insurance industry for 25+ years and prescription benefit management for 15 years. With that in mind, there are multiple debatable statements in that article:
FIRST
This is about Medicare part B and D, not insurance in general. These are very specific plans (that frankly aren’t all that great anyway) that are government backed, not private insurance
SECOND
Those who qualify for part B qualify for part D so which part pays for what actually isn’t a patient issue, it’s a doctor issue. With part B doctors bill for an office visit as well as medication dispensed. With part D medications are able to be self-admin by the patient. How a med is dispensed is critical. Some specialty meds can’t be self dispensed, others can be. Either way, if a med is moved from doctor dispensed specialty to patient admin specialty the doctor is losing money, as the patient your medication copay structure remains in place. Now, the copay structure is different under Med B than Med D but patients could pay less overall, it depends on the plan
THIRD
the statement is made “And because Medicare Part D does not allow for supplemental coverage…” this is absolutely false, your supplemental insurance has nothing do with how Med D bills or pays, supplemental insurance is patient directed, not primary plan directed
FOURTH
the statement is made " reducing physician reimbursements for new drugs below the current payment rates would create access issues" … read that statement again. It’s about physician reimbursement, not patient pay and it implies that if reimbursement isn’t what they want they won’t do it creating access issues… this is physician payment issue. When a doctor agrees to take Medicare patients they agree to abide by the program reimbursement rates, they agree to be in-network at the network discount… again, this is not about patients or medications at all, this is about how much money the doctor will make
FIFTH
the statement is made “Medicare Part B and D are distinctly different programs with differing formulary structures and cost sharing that would be difficult to consolidate without significantly increasing out-of-pocket costs for patients”… again, not true. The doctors that wrote this info up have no idea what your copay structure is or what you pay for Med D coverage. You could easily come out ahead! The copay you pay is between you and your plan, it has nothing to do with the difference in formularies between Med B and Med D, these are two different plans with different parameters. You can’t compare apples to oranges. Changing coverage from B to D is not consolidation by any means, it’s a plan update… an update which will probably make Med D coverage better. In fact, most Med D plans allow you to purchase a 90 day supply at a time at a good discount. Med B it typically limited to 30 days and often requires you to go the doctor every month.
SIXTH
statement was made “changing Medicare Part D formulary standards to require a minimum of only one drug per class”… the requiring of one drug per class is one PREFERRED drug, not just one drug in a category. Other drugs in the same category are available as non-pref or with a prior auth, or all kinds of drugs could be preferred. Med D does not limit the number of drugs in a category, this statement is false
SEVENTH
statement made “Establishing a beneficiary out-of-pocket maximum in the Medicare Part D catastrophic phase” ---- that’s part of all Med D plans already, you hit your out-of-pocket and the plan takes over close to 100% if not completely 100%… this is suggestion something that is part of every plan already (apparently to make scary statements for the sake of making scary statements)
EIGHT
statement made “Decreasing the concentration in the pharmacy benefit manager (PBM) market and other segments of the supply chain” … don’t even know what this means, other then the idea that doctors want PBMs out of the way so they can charge more. I work for a PBM, our goal is to drive medication pricing down and provide wide access to meds at the lowest possible cost to insurance companies and patients (not doctors) … doctors traditionally have nothing to do with PBM other than doing prior auths for insurance companies for certain coverages so why they want to decrease the concentration in the pharmacy benefit manager in the market is a mystery (sounds like wanting competition out the way, actually)
This ended up being longer than I intended, but the more I read the more I found. I hit the big highlights. Let me know if you have questions about anything I’ve said.
At the end of the day it sounds to me like doctors are complaining about THEIR reimbursement and trying to scary YOU about it.
azurelle
That was not quite hitting the mark with that article, here is one by “uspharmacist.com” bringing biogic distrubution to the local pharmacist. I think that might have been what she is talking about; if the classification of biologics change from Specialty to the regular pharmacy, the percentage that is paid by the insurance company will be lower. I get very little reduction in phrarmacuitical reinbursement, if any, and I have a Planinum PPO plan costing $1,600 a month. This is just being kicked around now, it is not finalized.
https://www.uspharmacist.com/article/community-and-specialty-pharmacy-at-a-crossroads
If you find anything about the proposed changes in the “Specialty” status, let us know…
Thanks!
I think you are referring to the equal access law. I’m not sure it’s still alive as it was a part of the last administration s additions to “Obama care” an other part of the bill included student loan forgiveness for entering certain specialties on of which was pediatric rheumatology. I was able to testify on behalf of the arthritis society on this part.
I understand what auzerelle was referring to which is different than access All biologics are tier 5 drugs no matter where the come from meaning with the best of part d plans, out of pocket costs will far exceed 10,000 dollars year. First you pay your deductible for most that is 1500.00 then again depending on the plan, tier 5 drugs require a 30 - 40% copay which for humira runs roughly 1600.00 until the part d has paid somewhere in the neighborhood of 6000.00 out of pocket when the next 6000 is paid 100% out of pocket and then it goes back to 20% or so. Co-payment
The law jons doc was referring essentially eliminate s the tier structure for many meds. Tho equal acess version died and was replaced by the Creates act which I’m sure is what Jon’s doc is referring to. https://www.leahy.senate.gov/download/creates-act-115th-congress
It’s actually pretty brilliant as it could move biologics into class 1 meds and with the donut hole going away in two years would make access to bioSimilars free or maybe 100.00 year.
Needless to say this act has the company execs in a complete dither…
What auzerelle was referring to and Jon’s link was referring to. is dealing with work arounds While some drug companies are developing biologics pills the wise ones have developed iv drugs which have to be admistered in infusion centers and are covered by part b which for most of us is zero out of pocket. My guess is this is why Jon is on remicade. At one point you could drop by your doc’s office for a shot of enbrel and have it covered by part B
Needless to say the insurance companies selling supplements hate this and medicare really hates it because infusion drugs are far more expensive and part d medications result in zero expense to Medicare.
So what we have is the insurance companies vs the drug companies. Which industry own the most congressmen?
Oh there is one other clinker medicare patients are eligible for many/most drug assistance programs.
Good synopsis, however, I am actually on regular insurance, Platinum PPO plan, and the reason I am on Remicade is that I have bombed out on all the others. My Rheumy does a lot of community work “downtown” so she might have been more miffed about the changes in Medicare and poor people getting these medications. She did not site any bills being put forth, I imagine her Big Pharma reps are screaming about changes. She is also involved in the Rheumatology Organization, sitting on some panels to try and help regulate this.
We are at a crossroads with Obamacare going out and something coming in, who knows what it will look like when they finally come up with a replacement, but I think specialty drugs and chronic patients may be left to fend for themselves, if they choose to exclude them from the insurance base to lower insurance costs. I think this is why they are trying to bring the drugs down to the local pharmacist, and take them away from the specialty pharmacy. We shall see what happens…
I can’t see infusion drugs being sold in a pharmacy, as you need a infusion center to give the drug, but the injectables could be transferred to the Mom and Pop pharmacy. When I got my first two infusions at a hospital out patient facility it was billed out to insurance at $33,000 and insurance paid $22,000! They allowed this for observation purposes.
The way it is now, the doctor fronts the money for the drug, it is infused in her office, then she has to wait a month for insurance to process the bill and reimburse her. This is also quite a burden on the doctor.
Well put Jon. BTW I get my humira from my regular pharmacy, course I just sold some acreage to pay for it…
Jon, thanks for posting that second article, that makes much sense as to what you were first saying.
tntlamb, I agree with you completely, the true issue is with big pharma “cooking the books” so to speak, trying to keep the cost of meds as high as possible. There seems to be trend of them doing this with an eye towards big insurance or big government footing the bill, they give little to no consideration to the patient at the far end of the pipelin in terms of cost. It’s basically coroporate piracy with one corporation attempting to raid another. Remember a few years ago when the cost of an EpiPen went up by something like 1000% in three weeks and lawyers had to get involved to force big pharm to adjust the price back? Same thing with biologics.
Biologics are the wave of the future, a wave that’s already here to some extent. The say biologics will make up 50% of the cost of prescriptions sold in the near future but this is very misleading. Biologics, as you all know, are currently wildly expensive, it’s not that more people will be using biologics to that extent, it’s the cost overall. For example, Hep C treatments average $20,000 a month and require a three month course treatment, and those are pills you take once a day! Insurance companies are pushing back hard on those kinds of costs trying to drive patient cost down by driving down manufacturer pricing that is artificially high.
I work for a PBM and a few years ago (after the EpiPen scandal) my company put into a place a rule of sorts. I don’t know the exact numbers, which would be propriatary anyway, but if a medication price increases by more than XX% in a period of time with no market-driven reason my company threatens to not cover it and advise insurance companies to not cover it. This way the price gouging is brought to heel as it doesn’t do any good to hike the price on something no one is willing to purchase.
Allowing big pharm to charge the stars and the moon for medications as they have been doing in the biologic category is not sustainable as big insurance can’t afford it, the government can’t afford it, and patients can’t afford it. Hence the push to move “speciality” meds to “regular” pharms. Meds need to be user friendly anyway, requiring infusing treatments isn’t that, especially when home injections or pills are readily available and simply not being brought to market to keep the price artificially high.
Now, don’t get me wrong. Big pharm needs to be able to recoup the developmental costs of meds. It takes about 15 years from start to finish to bring a med to market and costs untold millions of dollars. I’m not against big pharm making money by any means, making money drives invention. I’m against the bait-and-switch tatics that have come into play in last decade or so. One thing big pharm has been doing is releasing a “regular” med and then when it goes off patent they release and “extended release” version. Same med, same end result, one ingredient change, patent renews for another 10-15 years. Insanity, in my opinion. Sometimes they actually stop making the “regular” release and go strictly to “extended release.” This same basic thing seems to be starting to happen with biologics, hence the move to get them out of speciality and into regular channels.
azurelle