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Monthly Archives: August 2018
Aug22
0

States and the Trump Administration Rush To Cap Prescription Drug Costs

By Tom Matteson - blog

Many States along with the Trump Administration are trying are trying to curb the cost of prescriptions drugs.  Here is an article by the NY Times that should be helpful in understanding what is going on.

States Rush to Rein In Prescription Costs, and Drug Companies Fight Back

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Twenty-four states have passed 37 bills this year to curb rising prescription drug costs, according to Trish Riley, the executive director of the National Academy for State Health Policy.CreditJulio Cortez/Associated Press

By Robert Pear  Aug. 18, 2018

WASHINGTON — States around the country are clamping down on pharmaceutical companies, forcing them to disclose and justify price increases, but the drug manufacturers are fighting back, challenging the state laws as a violation of their constitutional rights.

Even more states are, for the first time, trying to regulate middlemen who play a crucial role by managing drug benefits for employers and insurers, while taking payments from drug companies in return for giving preferential treatment to their drugs.

The bipartisan efforts by states come as President Trump and his administration put pressure on drug companies to freeze prices and reduce out-of-pocket costs for consumers struggling to pay for drugs that often cost thousands of dollars a month.

Twenty-four states have passed 37 bills this year to curb rising prescription drug costs, according to Trish Riley, the executive director of the National Academy for State Health Policy, a nonpartisan forum of policymakers, and several state legislatures are still in session.

The burst of state activity on drug costs recalls the way states acted on their own to pass laws to expand health insurance coverage in the years before Congress passed the Affordable Care Act in 2010.

“In the absence of federal action, states are taking the lead in combating high drug prices,” said State Representative Sean Scanlon of Connecticut, a Democrat.

A bill passed unanimously this year by the Connecticut General Assembly illustrates a popular tactic: States are shining a spotlight on drug price increases as a first step toward controlling costs.

Under the Connecticut law, drug companies must justify price increases for certain drugs if the price rises by at least 20 percent in one year or 50 percent over three years. Insurers must identify their 25 highest-cost drugs and the 25 with the greatest cost increases when they file their annual rate requests with the state Insurance Department.

In addition, the middlemen, known as pharmacy benefit managers, must disclose the amount of rebates and other price concessions they receive from drug companies.

“As state legislators, we are responsible for the wise stewardship of taxpayers’ money,” said State Representative Norm Thurston of Utah, a Republican. “The state spends a lot of taxpayers’ money on prescription drugs, through Medicaid, corrections and jails, state employees, higher education employees and their dependents. We should be sure we’re getting the best deal.”

In response to a bill introduced by Mr. Thurston, the Utah Health Department is studying possible ways to import prescription drugs from Canada, and he is working with a Republican state senator on a bill to require the reporting of price information by drug companies.

California has adopted a law requiring drug companies to provide advance notice of price increases, together with a detailed statement of the reasons for the increases. In addition, insurers must file annual reports showing the percentage of premiums attributable to drug costs.

“Californians have a right to know why their medication costs are out of control, especially when pharmaceutical profits are soaring,” Gov. Jerry Brown said.

Drug companies have filed suit to block the California law, which they describe as “unprecedented and unconstitutional.”

The law “exports California’s policy choices” to the rest of the country and violates the First Amendment by compelling drug manufacturers to explain their price increases, said the lawsuit, filed by the Pharmaceutical Research and Manufacturers of America.

PhRMA, along with the Biotechnology Innovation Organization, also went to court to challenge a law signed by Gov. Brian Sandoval of Nevada, a Republican.

The Nevada law requires manufacturers of diabetes medicines, such as insulin, to report detailed information, including the production costs for each drug, the amount spent to market it, the profits earned on its sales and the amount of rebates paid to pharmacy benefit managers for sales of the drug in Nevada.

Drug companies dropped the lawsuit in June after Nevada agreed that certain information in the drug price reports could be kept confidential.

Reining in drug costs is a top priority for state officials who run Medicaid, the health program that serves more than 70 million low-income people.

Oklahoma will soon start paying for some prescription drugs based on how well they work. If a drug does not perform as promised, the manufacturer will refund the cost of the drug or another negotiated amount.

“If a drug claims to keep people out of the hospital and doesn’t, the manufacturer may be liable for the cost of the hospitalization,” said Nancy Nesser, the pharmacy director of the Oklahoma Medicaid program.

New York has imposed an annual cap on drug spending in its Medicaid program. If spending is projected to exceed the cap in any year, state officials must identify drugs responsible for the excess costs and try to negotiate additional rebates with drug manufacturers to keep spending under the cap. If a drug company balks, the state can restrict access to its drugs or impose controls on their use, based on advice from an independent panel that reviews the drugs’ costs and clinical benefits.

In the first year of the program, which ended in March, spending was on track to exceed the target, but state officials say they extracted $60 million in additional savings for the state through negotiations with companies that produce 30 particularly high-cost drugs.

In Ohio, Medicaid officials announced this past week that they had a new way to pay for prescription drugs. Pharmacy benefit managers will no longer be allowed to keep any of the payments they receive from drug manufacturers. The money must be passed on to Medicaid health plans and used for the benefit of Medicaid recipients, starting Jan. 1.

Ohio officials said they wanted to know whether the benefit managers had been overcharging the state, but were frustrated in trying to obtain drug pricing information.

“It’s shrouded in secrecy,” said Tom Betti, a spokesman for the Ohio Medicaid agency. “We intend to open up the black box.”

Maine adopted a law last month doing something that Congress has been trying, without success, to do for several years. The law requires manufacturers of brand-name drugs to make samples available to generic drug companies trying to develop inexpensive copies of those products. Generic drug developers need the samples to show that a low-cost generic copy is equivalent to the brand-name original.

The stated goal of the Maine law is to promote competition, so consumers do not have to pay “monopoly drug prices.”

A growing number of states have passed laws to ensure that pharmacists can inform customers of less expensive options. These laws ban “gag clauses,” which prevent pharmacists from telling consumers when they could save money on prescriptions by paying cash rather than using their health insurance.

Maryland tried a particularly bold approach.

After reports of huge increases in the prices of certain generic drugs, Maryland banned “price gouging,” defined as an unconscionable increase in the price of any “essential off-patent or generic drug.” A drug company that flouts the law could be fined $10,000 and be required to pay refunds to consumers.

The lobby for generic drug companies, the Association for Accessible Medicines, filed suit to block the law, and the United States Court of Appeals for the Fourth Circuit, in Richmond, Va., struck down the law, saying it interfered with interstate commerce in violation of the Constitution.

Under the law, it said, Maryland would regulate prices in transactions that occur wholly outside its borders — prices charged by drug makers to wholesalers — regardless of whether any pills were ever shipped to Maryland.

In a lengthy dissent, Judge James A. Wynn Jr. said that Maryland should be able to protect the health and welfare of its citizens. The court, he said, was accepting the drug companies’ view that they were “constitutionally entitled to impose conscience-shocking price increases” on consumers.

Aug13
0

CMS to Allow Medicare Advantage Plans to Restrict Access to Drugs Covered Under Part B

By Tom Matteson - blog

When a person has Part B of Medicare typically any medication that is administered at the doctor’s office, or in the hospital, are covered by Medicare.  This also was the case for Medicare advantage plans, aka Part C of Medicare.  However, per CMS this is about to change for Medicare advantage plans.  The new rule will allow Medicare advantage plan providers to not cover certain medications administered by a provider(doctor/hospital).  For Example:  Drugs used in durable medical equipment, anti-rejection drugs for people who had Medicare when they got a transplant, and some chemotherapy agents, as well as drugs that are both supplied by and administered by a provider.  Here is a nice piece by Casey Schwarz of the Medicare Rights Group filing us in on the changes.

CMS to Allow Medicare Advantage Plans to Restrict Access to Drugs Covered Under Part B

Casey SchwarzAugust 9, 2018

This week, the Centers for Medicare & Medicaid Services (CMS) announced that next year, Medicare Advantage (MA) Plans will be able to limit options for people who get Part B-covered drugs by using many of the same tools plans currently use in Part D. The Trump administration argues that this will enable plans to negotiate better prices for the “preferred” medications – those that the plan will cover as a first-line treatment. Other drugs will only be covered if a person tries the preferred medication first and it doesn’t work or causes them harm, also known as step therapy.

Until now, MA plans were not permitted to place this type of restriction on medications covered under Part B. Part B drugs include drugs used in durable medical equipment, anti-rejection drugs for people who had Medicare when they got a transplant, and some chemotherapy agents, as well as drugs that are both supplied by and administered by a provider. Plans that have both MA and Part D coverage will be permitted to create combined step therapy requirements where a preferred Part B-covered medication must be tried before a non-preferred Part D-covered treatment.

These restrictions, which are common in Part D plans, can make comparing plans more difficult. While CMS requires plans to announce to enrollees that they intend to use this flexibility in the Annual Notice of Change, they do not require plans to send personalized or targeted notices to people currently taking, or who have a diagnosis that might require, the affected medications. Medicare Rights is concerned that it will be especially challenging to compare plans where Part B step therapy is used unless there are updates and improvements to the Medicare Plan Finder tool.

Aug6
0

Does Medicare Cover Chiropractic or Acupuncture?

By Tom Matteson - blog

Medicare does cover chiropractic care, but does not cover acupuncture at this time.  Here is a great article by Medicare FAQ that jumps into the topic with both feet.

Often times, in the weeks following an injury or when pain becomes too much to deal with, patients will seek the support of a chiropractor, or acupuncture specialist. Both acupuncture, and chiropractic care, were created to treat moderate to high level pain and discomfort.

However, one concern that always comes to mind is out-of-pocket expenses, which can definitely add up. So naturally, this has Medicare beneficiaries wondering just how much of these treatment costs are covered by their Medicare plan, if covered at all.

Chiropractic Care vs. Acupuncture

Like stated above, both of these methods of treatment were created to relieve pain or discomfort. Before looking into the cost difference between the two, you may consider what each form of treatment entails. It is best to look further into both before deciding on the best option for you.

Does Medicare Cover Chiropractic

Chiropractic

Chiropractic care is a very hands-on process. For chiropractic treatments, the physician uses his or her hands to adjust the patients muscles and joints. This is done to generate better movement to tight muscles and gain better usage of affected joints.

Neck pain, back pain, headaches, or anything that may cause a disruption in the nervous system, are usually a common reason patients seek chiropractic care. Patients who receive this form of treatment typically feel results immediately after leaving the appointment.

However, chiropractic care does come with a few possible risks. Amongst them, are risks of having a stroke or unintentionally adding pressure to the injury. The risk is low with certified practitioners, but with constant shifting of muscles and joints, you could possibly end up being be more susceptible to injury.

Acupuncture

Does Medicare Cover Acupuncture

Unlike chiropractic care, acupuncture is not as much of a hands-on method for reducing pain. Acupuncture is done by inserting needles into the surface of the skin. This is a practice that will stimulate certain parts of the body to alleviate pain, and can also help to treat several other medical health conditions.

In fact, several acupuncture patients have reported that this treatment has helped cure their depression, anxiety, and several other mental and physical issues. Again, like chiropractic care, acupuncture does come with some low risks. Acupuncture risks can include bleeding or bruising from the needles, infection, and in some cases can stimulate labor for pregnant women.

If you are considering acupuncture treatment, just be sure you choose a licensed practitioner.
It is important to note that, while both are proven effective and useful options, there are differences in what Medicare plans will cover.

Does Medicare Cover Chiropractic Care

Yes, Medicare covers chiropractic services, if they are medically necessary. Luckily, Medicare currently has no cap on how many times you can see a physician for necessary chiropractic appointments.

If you are enrolled in Medicare Part B, 80% of the cost for chiropractic care will be covered by Medicare. If you have the Original Medicare, and don’t have any other additional insurance, you are responsible for paying your Part B deductible, and a 20% coinsurance for your appointments.

You may also be required to pay for any additional tests that are ordered by your chiropractic physician. This can include, x-rays, any extra physical or massage therapy, and even, coincidentally, acupuncture. The specific amount of money owed will depend on several factors, including:

  • Any other insurance you have.
  • The facility that you seek care from.
  • How much your individual doctor charges.
  • Where you get your tests and services.

Do not go into this treatment with no knowledge of the average estimate of payment. Talk to your doctor, and get all of your questions answered before committing to a certain recommendation they’ve made.

Is Acupuncture Covered by Medicare

Unfortunately, no. At this time, acupuncture specifically is not covered by your Original Medicare plan. Medicare typically does not cover services that are not considered medically necessary. Medicare will cover other types of therapy, like physical, occupational, or speech therapy. However, acupuncture is not part of those types of therapy yet.

If you should decide to seek the help of a professional acupuncturist, it is important to be quoted on prices for the entire process. Patients typically get the initial first visit cost, and tend to forget any additional costs for follow up appointments or extra care.

Find out how many appointments you’ll need to attend. If there are any additional costs, and how often you’ll need to attend follow-up visits.

Acupuncture and Chiropractic Coverage with Medigap

What is Medigap? Medigap provides you with any additional coverage you may need when paying for your medical needs under Medicare. So are acupuncture and chiropractic care part of the additional coverage?

At this time, Medigap plans do not cover any costs that deal with acupuncture.
While acupuncture is not covered by Medigap, chiropractic care is covered by Medigap. In fact, Medigap Plan C and Plan F cover 100% of your Part B deductible, on top of your 20% coinsurance.

If you combine your Medicare and Medigap plans, any medically necessary chiropractic work will be completely covered, at no cost to you.

Does Medicare Advantage Cover Chiropractic and Acupuncture?

When it comes to Medicare Advantage plans, we hit a bit of a grey area with coverage for chiropractic care or acupuncture treatment. Each Medicare Advantage plan is different from the next. So one plan may offer high fees and less benefits, while another offers low fees and more benefits.

At this point, it may be tough finding a Medicare Advantage provider that covers acupuncture. It may be worth looking into though, if it is something you truly feel is a priority for your health.
The same answer goes for chiropractic services. Although it is usually much easier to come across, the prices and plans will vary.

 

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