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Congress Should Explore Patient Access and Outcomes in Confirmation Hearings for Medicare Chief

by Michael Rule, Associate Director Public Affairs and Grassroots | Feb 15, 2017

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The upcoming hearing by the Senate Finance committee to vet the nomination of Seema Verma to be administrator of the Centers for Medicare & Medicaid Services (CMS) is perhaps the most important non-cabinet level confirmation hearing the Senate will hold. The Trump Administration and Congressional leaders have laid out a robust health care agenda for the current Congress, and many of these policies would have an effect, either directly or indirectly, on patient access to affordable prescription medications, which would ultimately fall on CMS to implement.

For example, several legislators have voiced support for reforming Medicaid by providing block grants to the states, which they say would allow individual states greater latitude in administering the program. Ms. Verma should be asked to explain how she would balance such reforms with the need to maintain beneficiary access to health care providers, including independent community pharmacists.

Unfortunately, block grants encourage states to implement managed care programs, which can sometimes mean narrower provider networks. Medicaid beneficiaries may need to travel great distances to visit an in-network pharmacy to fill their prescriptions. This could have costly repercussions, with some beneficiaries choosing not to fill their prescriptions at all. Prescription drug non-adherence, or not taking medications as directed, is estimated to cost the health care system up to $290 billion/year. Non-adherence can result in patients experiencing complications from their condition and then having to seek out more costly, but avoidable, treatments in hospitals or emergency rooms.

Independent community pharmacists serve on the front lines of our health care system, and are often located in traditionally underserved rural and urban communities. Access to these pharmacies is critical for Medicaid beneficiaries. Prescription medications are the primary method of treating chronic disease, and are involved in 80% of all treatment regimens. Medicaid accounts for 17% of prescription volume for the average independent pharmacy, suggesting many Medicaid beneficiaries rely on access to those pharmacies for such prescription treatments.

Ms. Verma should be asked to explain how she believes such reforms would ultimately lower health care costs. Indeed, a recent Medicaid and CHIP Payment and Access Commission ("MACPAC") report questions the cost savings of managed care prescription drug programs. The findings indicate that state fee-for-service Medicaid programs are better at negotiating larger rebates on drugs than their managed care counterparts. It's important for CMS to work with states to develop Medicaid prescription drug programs that promote patient choice, encourage provider participation, and lower overall costs to the program.

If confirmed, Ms. Verma also will have responsibility for overseeing CMS' jurisdiction over Medicare Part D. In 2014, CMS issued a rule that required greater transparency in how Medicare prescription drug plans (PDPs) set reimbursements for many generic medications, yet this rule has largely gone unenforced. CMS leadership should commit to fully enforcing regulations resulting from formal rule making efforts.

In addition, a recent report by CMS questioned the value of direct and indirect remuneration (DIR) fees charged to pharmacies by PDPs. The report noted that such fees do not lower prices for beneficiaries at point of sale, force beneficiaries into the coverage gap prematurely, and shift more of the financial risks to Medicare and taxpayers. Proposed guidance that would require plans to reflect most, if not all, of these fees at point of sale has been languishing at CMS for nearly two years. It reinforces the need for CMS to finalize this guidance and for Congress to pass legislation to ban retroactive pharmacy DIR fees, and Ms. Verma should be asked about her position on this subject.

These are just a few issues under the purview of CMS that are important to independent community pharmacists. We urge Ms. Verma to promote access to care and safeguard the integrity of the programs she will likely be entrusted to oversee.

Community pharmacists wish Ms. Verma well in her hearing and look forward to working with her upon her confirmation on health solutions that improve patient outcomes and reduce costs.