CMS Updates: New Emergency Preparedness Rule Announced

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

The Centers for Medicare & Medicaid Services (CMS) recently finalized a new rule to be implemented by November 15, 2017 to create consistent emergency preparedness requirements for participating Medicare and Medicaid health care providers, as well as a better coordinated response to both man-made and natural disasters in an effort to increase patient safety during times of emergency.

Before we dive into some of the specifics, let us answer the question: Why was this new rule proposed and officially finalized in September 2016? 

CMS explains that over the past few years, there have been several man-made and natural catastrophes that have resulted in the health and safety of Medicare and Medicaid beneficiaries being put at great risk. As a result, the purpose of the new emergency preparedness requirements is to have participating providers and suppliers be more prepared to cater to patients during any future disaster or other emergency. Ultimately, these providers and suppliers will need to work with state, tribal, regional, local and federal emergency preparedness systems in an effort to make sure that their facilities are ready to care for patients.

After an in-depth review of current emergency preparedness rules and regulations, CMS hopes to bridge any gaps that were originally present by requiring providers and suppliers, who participate in Medicare or Medicaid, to take the following actions:

1. Create an emergency plan. Participating providers must come up with an emergency plan using an all-hazards approach that focuses on “capacities and capabilities that are critical to preparedness for a full spectrum of emergencies or disasters specific to the location of a provider or supplier”.
2. Establish policies and procedures. Participating providers must create, and then implement, policies and procedures based upon their risk assessment and emergency plan.
3. Have a communication plan. Participating providers will need to come up with a communication plan that is aligned with Federal and State law. CMS explains that within this plan, “patient care must be well-coordinated within the facility, across health care providers, and with State and local public health departments and emergency systems”.
4. Develop a training and testing program. Participating providers are expected to create and maintain strong training and testing programs – both initial and annual trainings are to be included. They must also take part in drills and exercises OR take part in an incident that tests the success of the plan.

For additional specifics about the CMS’ new emergency preparedness requirements, check out this chart, where the requirements are outlined based on provider type.

PBIRx has been exclusively providing intelligent solutions to clients in the management of pharmacy benefit costs since 1993. With a staff that includes IT personnel, actuaries, financial analysts, clinical pharmacists, attorneys, HIPAA Compliance Officers and many more experts, PBIRx’s mission is to create optimal health care outcomes while minimizing overall health care costs. For more information, please visit www.pbirx.com or call (888) 797-2479.

Rising Drug Costs, the Government, and the 2016 Election

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

Election year is always bound to include debate and discussion over major topics that the public has their eyes and ears on, and this year, one of the most pressing that we are following is rising drug costs - one piece of the health care puzzle that has been at the forefront of many conversations.

Thanks to recent price hikes, such as the one seen with EpiPens, it appears that more people are looking for answers from officials about the issues surrounding exceedingly high prescription costs. During a forum sponsored by RealClearHealth and Express Scripts earlier this month, congressmen and industry leaders took an interest in how the rising cost of drugs should be addressed. While some attendees from the left feel that caps on prescription drugs or negotiations between the Centers for Medicare & Medicaid Services and pharmaceutical manufacturers are the answers, others are looking for more transparency and expressed that there needs to be more congressional oversight. Another opinion is that the FDA needs to have a more efficient process for approving new drugs, as they currently have a “backlog of generics to approve,” which encourages prescription costs to keep rising (additional details about the forum available here, via RealClearPolitics).

The Presidential Candidates and Their Health Care Plans

A recent article by MedCity News reports that Democrat Hillary Clinton just announced her plan for how she will respond to “unjustified price hikes for long-available drugs.” Considering that drug makers have hiked prices for about 400 generic drugs by more than 1,000% between 2008 and 2015 alone, part of Clinton’s plan is to “establish dedicated consumer oversight at our public health and competition agencies.” She strives to bring together representatives of federal agencies that are responsible for ensuring health and safety, as well as fair competition, in order to create a group that is dedicated to protecting consumers from such price increases. Should we experience another price hike similar to what happened with EpiPens, for example, it would be this group’s duty to respond (read the full details of Hillary’s health care plans here).

Republican Donald Trump has also expressed his viewpoint on health care reform, with one of his main priorities being to repeal Obamacare. Should he be elected President, some of his other plans include:

1. To require price transparency from all health care providers, while permitting individuals to find the best prices for their medical needs.
2. To remove existing barriers to entry into free markets for drug providers that are offering reliable, safe, and cheaper products.
3. To give individuals the opportunity to fully deduct their health insurance premium payments from their tax returns under the current tax system.

Initiatives such as these have been designed for the purpose of reducing health care costs for more Americans, according to the campaign. Additional details about Trump’s plans can be found here.

Other Government and Health Care News

Insurers such as UnitedHealth Group Inc., Aetna Inc., and Humana Inc. recently announced that they will be pulling back from the Obamacare individual insurance market next year, and as such, earlier this month, President Obama and other health advisers met with other insurance companies to discuss how the marketplace can be strengthened before the open enrollment period begins in November. The President did openly acknowledge that improvements could be made to benefit both consumers and insurers, and says that his administration will focus on enrolling individuals who are still without health coverage, such as young adults. More on this available here, via The Financial Express.

As election day gets closer, be sure to connect with PBIRx on social media and check our blog regularly for updates on health care’s role in the election. For additional information, please call (888) 797-2479.

EpiPen Costs Skyrocket, Cause Outrage

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

We are sure you have heard some talk about the EpiPen lately, but in case you missed it, earlier this year Mylan raised the cost of a pack to be more than $600 - a significant hike from what it originally cost when the company first purchased the rights to the drug/device in 2007 (at that time, EpiPens cost about $57 each). Since 2007, NBC News reports that the following actions have been taken:

• In 2008 and 2009, Mylan raised the price of EpiPens by 5%.
• At the end of 2009, Mylan tried a 19% price hike.
• From 2010-2013, there was a succession of 10% price hikes.
• From Q4 of 2013 to Q2 of 2016, Mylan raised EpiPen prices by 15% every other quarter.

It is no surprise that consumers are outraged over the EpiPen's new cost, as these are used for life threatening allergic reactions. With the new school year approaching many have a need to purchase an EpiPen and provide it to the school nurse, but the cost has made this increasingly difficult.

So why is the price of EpiPens so inflated?

Although it only costs about a few dollars to make (CNBC reports that only about $1 worth of epinephrine is used in these devices), there is currently NO EpiPen generic available in the United States. However, after the uproar began and Mylan faced more scrutiny from both consumers and Congress, they just announced that they will be launching a generic version of EpiPens for about half of the current price ($300). Teva Pharmaceuticals is also working on its own generic version of the EpiPen, and expects to receive approval sometime next year.

Mylan has also taken other actions to try and make EpiPens more affordable to consumers and members, such as by increasing the consumer/member out of pocket cost reduction from "up to" $100 to "up to" $300 - more details available here.

All that said, it is important for payors to understand that increased costs will be experienced, not only because of the increase in prescription costs for EpiPens, but also because of increased and conceivably unnecessary utilization or stockpiling of the brand drug. Additionally, offering a coupon for EpiPens will result in higher costs because eliminating the member copay results in brand loyalty, even though a lower cost generic will be available soon.

This is where we at PBIRx come in. We fight for our clients to get the most value for their health care dollars, and are well aware of the tactics used by Big Pharma to take advantage of consumers. If you have questions about the recent EpiPen news or would like to learn more about how we can help you during this time, please call (888) 797-2479 today.

Three Reasons To Work With PBIRx In 2016

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

For those of you who are unfamiliar with our business, we are a pharmacy benefit auditing and consulting firm that strives to establish and maintain professional relationships with brokerage firms, consulting firms and various other entities that provide pharmacy benefits to their employees or members. Our main goal is to aid with the management of pharmacy benefit costs, and we work closely with each client to ensure that they are receiving optimal health care outcomes at the lowest possible costs. But what makes us the ideal candidate to work with your company? Below, we discuss a few advantages of partnering with our team.

Pharmacy Benefit Consulting Is Our Specialty

For over thirty years, PBIRx has specialized exclusively in consulting for pharmacy benefits. That means our attention is 100% on finding and delivering solutions that will aid in the management of pharmacy benefit costs specifically! With us, you can feel confident that we are solely focused on the outcomes that best meet the specific goals you require.

Our Staff Is Top Notch

We are not just staffed with a few pharmacy benefit management experts; we also have actuaries, financial analysts, clinical pharmacists, HIPAA compliance officers and IT personnel on hand to assist with each of our services. Did you know that our actuary is even a Fellow in the Society of Actuaries and a Member of the American Academy of Actuaries? At PBIRx, we are only staffed with the best!

We Are Efficient and Honest

Data processing can be time consuming, but we have developed a strategy that allows us to be as efficient as possible in processing any information we are working with. Additionally, through each of our services, we will always offer an unbiased and objective financial analysis that considers the client’s best interests, rather than the PBM’s. If you are looking for a reliable consulting firm that will provide you with honest answers, we are surely the one to turn to.

Interested in learning more about our team and the services we can offer you in 2016? For further information, please visit www.pbirx.com or give us a call at (888) 797-2479 today.

Get Control Over Your Health Care Costs In 2016 With PBIRx

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

Just like we all set individual goals for ourselves when the first of every new year rolls around, it is important for businesses to do the same. As experts in the pharmacy benefit field, something we recommend is for business leaders to look deeper into their health care spend and see what total health care costs look like. And if, in fact, pharmacy benefit spend specifically is over budget, it is time to take more control. Below, take a look at how the PBIRx team can help with doing so.

Pharmacy Benefit Consulting

Through our pharmacy benefit consulting services, we will deliver our unbiased, objective financial analysis to you that considers both sensitivity to member and client impact after a comprehensive client needs analysis and discussion. Utilizing our knowledge of, and ability to anticipate change to the industry, we will provide you with our savings projections based on actual claim utilization, which is measured monthly and reported back to every client demonstrating our dedication to making accurate savings projections for clients.

Pharmacy Benefit Auditing

Our proprietary prescription claim audit program, AuditRx®, was designed to help your company get more control over the terms in your contract with your PBM. Through this service, we can help negotiate recoveries for times when there was a difference in claims billed versus your contract’s language. PBIRx AuditRx is used for commercial PBM auditing, 340B auditing and Medicare Part D auditing. 

Third Party 340B Compliance Audits

Covered entities may lose their 340B status if they are not completely compliant with the program, which is why we can provide a compliance audit that helps determine any potential cause for concern. Completed on site, our reports will help prepare you for a true HRSA audit of this nature. References include clients who retained PBIRx for second audits after having successfully passed a HRSA audit after PBIRx compliance audit. 

Clinical Technology Intelligence (CTIRx)

The goal of our CTIRx service is to promote clinically appropriate prescription drug utilization, that results in positive health care outcomes adjunct to pharmacy benefit savings. What we do here is run your claims through our CTIRx data processor, then analyze the findings to devise strategies that can lead to pharmacy savings. PBIRx staffs a large IT department including programmers and clinicians. As a result proprietary clinical algorithms are built and managed so that a Clinical Recommendation and Savings report can run within an hour of receiving actual client claims utilization.  

Pharmacy Benefit Actuarial Services

This particular service comes in handy for those who offer pharmacy benefits to retired employees or employees who are eligible for Medicare. Since the government provides a 28% drug subsidy for qualified retiree plans, it is important for you to determine if you are eligible and if so, know how to proceed; through this service, our team will help you with all of that. Fee estimates are provided at no charge after initial review of data.

Considering that health care costs are still on the rise, we encourage you to start speaking with an expert like ourselves to make sure you are properly managing yours. To learn more about each of our services and how you can take advantage of them in 2016, please call (888) 797-2479 or fill out our online contact form.

Medicare Proposes Lower Drug Reimbursements to Hospitals and Doctors

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

Earlier this month, Medicare announced a plan to change how they reimburse doctors and hospitals for certain medications under Medicare Part B in order to encourage them to choose less expensive drug treatments for patients. Specifically, the drugs to be targeted under this new proposal include intravenous medications, injectable drugs and some eye treatments. 

As of right now, the Medicare Part B program reimburses doctors and hospitals for the “average price” of the medication used plus an additional 6% fee. Thus, doctors and hospitals bring in more of a profit when they decide to use drug treatments that are on the expensive side. However, under a new reimbursement program, Medicare is proposing to lower the reimbursement for Medicare Part B drugs to “average price” plus 2.5% along with a flat fee of $16.80 per drug per day. As a result of the new method of reimbursement, the Centers for Medicare and Medicaid Services (CMS) hopes that doctors and hospitals would be more inclined to choose less costly treatments, especially since they often choose high-priced drugs even though lower cost, same efficacious therapies are available.

Value-Based Pricing

In addition to changing the way doctors and hospitals are reimbursed for certain services, CMS is also hoping to test what they call “value-based pricing” programs, something similar to what some pharmacy benefit managers and commercial health plans are already testing. One example is the indication-based pricing idea, which would cause reimbursement amounts to vary depending on how effective a drug is in treating a type of cancer. Essentially, if one particular type of cancer therapy is used to treat different conditions and has more success in one over the other, the plan is to pay for what works best for optimal health care outcomes at the lowest cost.

Medicare Proposal Critiques

Although some may welcome this proposal, many have expressed their concern - particularly some drug manufacturers and cancer doctors. In their eyes, this new plan is too heavily focused on saving money rather than the patient’s best interest. Furthermore, they suggest that following through with these changes to Medicare Part B could “limit access to care for some of the sickest Medicare beneficiaries,” according to The New York Times. Although the Obama administration has expressed that these changes are not intended to disrupt or interfere with a doctor’s true medical judgement or their ability to order Medicare Part B drugs when appropriate, doctors and hospitals continue to remain skeptical of the proposal.

As a pharmacy benefit consulting firm that works with a diverse group of clients including hospitals, we are always on the lookout for information about how they may be affected by industry changes. If you have questions about the Medicare Part B proposal or are curious to learn more about how it could affect revenue for certain companies and organizations, please do not hesitate to call PBIRx at (888) 797-2479.

The Cybersecurity Act of 2015’s Effect on Health Care

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

On December 18, 2015, President Barack Obama signed the Cybersecurity Act of 2015 into law - an act that was a part of the federal omnibus government spending package. Within the Cybersecurity Act, approximately nine pages of health care related concerns are covered, outlining a plan for how to improve security within the health care system.

Considering that we live in a world nearly dominated by technology, it is not unusual to hear of cyber attacks and breaches in online security. However, knowing the nature of health care data passed through digital systems, it is important that action be taken to limit the amount of breaches that occur. Not to mention, a report from Accenture found that “data breaches over the next five years will cost U.S health systems $305 billion in cumulative lifetime revenue,” making it even more critical that something be done to prevent this.

Below, we highlight some of the main points regarding the health care industry that are included in the Cybersecurity Act:

1. According to congress.gov, the Department of Health and Human services must bring together a task force that can: a) put together a single system that the federal government can use to share intelligence about cybersecurity threats that affect the health care industry; and b) recommend protections for electronic health records and medical devices that are networked.
2. Within one year of the act’s enactment, the Secretary must submit a report on the preparedness of the health care industry when it comes to responding to cybersecurity threats to the Committee on Health, Education, Labor and Pensions of the Senate and the Committee on Energy and Commerce of the House of Representatives.
3. Information about how to improve preparedness for and responses to cybersecurity threats in the health care industry must be distributed to health care industry stakeholders.

For more information about improving cybersecurity in the health care industry, be sure to read through all of Section 405 of the Cybersecurity Act.

At PBIRx, we place a great deal of our focus on cybersecurity efforts to ensure that our clients’ data and protected health information (PHI) is kept secure. Not only have we worked to make our office a safe place through the use of access key pads and secure locks, but we have also worked with IT professionals to protect and encrypt any and all technological devices. For example, our computers become locked when not in use and we have software installed to prevent access to unsafe websites. Last but not least, our employees are required to attend quarterly cybersecurity trainings to ensure that they are up to date on the latest policies and procedures along with annual HIPAA Certification requirements.

For more information about PBIRx and how we work to protect our clients’ information, please give us a call at (888) 797-2479 today.

PBM’s Earnings Lead To Higher Health Care Costs and Harm Patients

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

You are likely already aware that health care costs are continuing to rise, which naturally makes it more difficult for patients to receive the services they require. However, did you know that the actions and ultimately the earnings that PBMs take and make are two of the primary reasons for this? In fact, an article from the Wilson County News reports that “in 2012, the CEO of the nation’s largest pharmacy benefit manager, Express Scripts, earned about $1 million every week.” With an income so great on a weekly basis, let alone what individuals of this status earn every month and so on, it seems only fair to question where it all comes from.

A main reason that PBMs can achieve such high earnings is due to the fact that they refuse to pay for medications that patients require - the less they cover, the more money they keep in their pocket by preferring drug alternatives for which the PBM has negotiated significant rebates and fees that are NOT shared with the client. As they continue to deny coverage for certain drugs and services (here is a list of some drugs that PBMs CVS/Caremark and Express Scripts will be excluding in 2016), they also make it more expensive for patients to receive what they need. In turn, health care costs continue to rise across the board and, in some cases, patients get sicker when the out-of-pocket costs become too much to cover.

Though they are an important part of our health care system, you must realize that PBMs will go to great lengths for their own benefit, including the fact that they will keep rebates for themselves rather than pass them along to the rightful pharmacy or insurance provider - another reason their earnings are so high. As a result, we cannot stress enough how important it is for providing entities to have their pharmacy benefit contracts audited to ensure that the financial components of the Agreement are competitive today and that the PBM is complying with the terms within. At PBIRx, our number one priority is to keep our client’s PBM Agreement financial model continuously reviewed and negotiated so that they can enjoy the added savings versus the PBM increasing their profits.

Remember that PBMs renegotiate with their pharmacy network every year and benefit from new pricing. Clients however, negotiate their PBM Agreement once every 2-5 years and at year two or three it is the PBM that has benefited from any new pricing, not the Client.

If you suspect that your PBM is holding back rebates that you are entitled to, or if you simply want to have your contract audited to ensure that your plan is being carried out correctly, do not hesitate to give us a call at (888) 797-2479. 

For more information about our services and how YOU can take control over your health care costs, please visit us on our website today.

PBIRx Is LIVE On Social Media

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

When you need information about pharmacy benefit plans, drug costs, health care reform and other similar topics, you need PBIRx. As a pharmacy benefit consulting and auditing company that works with a number of clients on their pharmacy benefits, we have dedicated ourselves to becoming a leading source of information on all subjects pertaining to the pharmaceutical and health care industries. 

To share our knowledge and expertise with others, we are active on the following social media sites:

Facebook

Twitter

Google+

LinkedIn

Last, but certainly not least, there is also our blog! From new FDA drug approvals to overviews on certain drug types and insider news, we have the details you need to stay up to date on the ever changing nature of our industry. And the best part is, you can subscribe to our blog via email so that you can be the first to know when we have published a new post. It's simple! Just enter your email address in the corresponding box on the right hand side of our blog's homepage.  

To learn more about the PBIRx team and how we can help you through our consulting and auditing services, please give us a call at 1 (888) RxPBIRx (797-2479). And don't forget to visit us on our website! We recently updated the layout and design, making it much more user friendly so that you can access everything you need with ease. 

Reasons Behind Non-Adherence in Patients

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

When presented with a medication or other health care service, one would naturally assume that the patient who received it would follow through. However, recent reports have shown that many patients actually fail to comply with several health care services, particularly prescription medications, and unfortunately, this has led to an increase in health care costs.

Earlier this month, Express Scripts reported that "non-adherence is a major contributor to skyrocketing health care costs as well as higher rates of hospital and ER visits for patients who do not take their medications." But why exactly are patients leaving their medications in the dust? Well, the report further explained that 69% of non-adherence by patients is a result of certain behaviors such as forgetfulness, procrastination and even confusion; when patients have multiple medications to take, it can be easy to get things mixed up. Additionally, aside from the patient's own behavior, the cost of such medications has also proven to be a cause of non-adherence in 16% of cases. Lastly, 15% of non-adherence is due to clinical side effects, according to the data provided by Express Scripts.

So what can be done to combat this issue? First and foremost, if a medication is too expensive or causes severe side effects, the first plan of action should be to switch it for that particular patient. Or, if there is no alternative, health care providers should work with the patient as closely as they can to make their current situation work. If copayments for mail order prescriptions and if mail order discounts are competitively negotiated by an independent third party like PBIRx, home delivery for medications can offer patients reminders so that they don't lose track of when it's time to take or renew a medication.

To learn more about non-adherence in patients, including how it is directly linked to rising health care costs, check out this article from HealthIT Analytics.

At PBIRx, we understand just how big a role non-adherence plays in health care costs. And as a company whose main priority is to reduce costs wherever possible for our clients, we encourage you to contact us if you're struggling to keep up with the rise in prices for prescription medications so that we can audit your pharmacy benefit plan. For more information, please call (888) 797-2479 or visit us at www.pbirx.com today.