Jodi Goldstein Daniel

Another section of the #FinalRule has been released by #CMS aimed at enhancing #access to and #transparency of #Medicaid services, including #HCBS. This rule pairs with two other final rules published in April 2024 that focus on improving Medicaid #eligibility and access to Medicaid services. This rule is focused on an #FFS system, but the impact could involve changes to underlying FFS rates in base #data for #ratesetting and program #oversight in #MLTSS. Dianne Heffron and Meredith Mayer of Mercer US Government have conducted a review of the proposed and finalized rules. https://bit.ly/3QuGRXe

33

“Although significant progress has been made over the last several years to introduce more standardization and connectivity between public health and health care IT systems, more work is needed. This commentary describes the benefits and potential of robust, modern interoperability between health care and public health systems, defines key policies and technology activities that will drive toward a future state of a highly connected public health and health care data ecosystem, and summarizes potential challenges that must be overcome.”

6

The Double Standard that Protects #CMS, #MAPlans, and #PBMs In 2007, 17 years ago, Judge Saris, in the #AWP case, took #drug makers to the watershed for EXACTLY what #CMS, #MedicareAdvantage plans, commercial payers, and #PBMs do to patients EVERY day. What was bad for the goose (manufacturers) is perfectly fine for the many ganders out there. It’s time to throw a flag on this ridiculous double standard. The Case: I’m rereading In re: AWP for the law school course I’m teaching in the Fall, and, as happens each time I read it, my head explodes. Judge Saris was merciless in her criticism of how Average Wholesale Price, because it did not reflect rebates and other discounts, affected patients. “Disturbingly”, Saris wrote, “the patient was a vulnerable victim” of AWP as the means to peg both #reimbursements and #copays. This was so, she said, because the “inflated” AWPs that did reflect rebates and discounts, meant that “the Medicare patient was required to make a co-payment” that was itself “inflated”. With obvious disgust, she concluded her rant by intoning that ”manufacturers understood well the harmful impact that publishing inflated AWPs had on the elderly cancer patient” through the inflated copays they paid. I wish that some of Judge Saris’ outrage could now be turned towards #Congress, #HHS, #CMS, MA plans, and their #PBMs. All of these “ganders” are responsible for inflated Part D “negotiated prices” that impose the very same kind of inflated #costsharing “percentages” on vulnerable patients. The “ganders” know that—but they have enshrined inflated prices in Part D “negotiated price” and profit of off it. The same dynamic exists in the commercial insurance market. The ganders don’t care. #InflationReductionAct supporters will say: “Ah ha—but that is the beauty of the the IRA. It will mean truly negotiated prices where a net price will be the basis of the cost share.” Well, I fear that is doubly wrong. First, that only applies, if it applies at all, to #IRA “selected drugs”. So many patients using so very many other #drugs are necessarily subjected to exactly the kind of inflated copays that Judge Saris decried under the #PartD statute’s “negotiated price” deception. Second, I’m skeptical that patients even get the benefit, at least in the early years of the IRA, of “select drug” copay rates, which, on paper, will be lower. Why’s that? As I have said before, I’m not understanding why plans and PBMs won’t push patients using those select drugs to high list/high rebate alternatives—forcing patients to continue to pay the inflated copays Judge Saris found “[d]isturbing”. Lower copays on paper that aren’t actually accessed don’t mean nothin’. Why hasn’t 17 YEARS been sufficient to systematically fix this #patientharm? Senator Sanders, let’s stop the finger pointing exercise, and just fix this problem. #lifesciences #drugpricing #managedcare #healthcare

32

6 Comments

Glad to share our upcoming Gainwell Technologies webinar on how our team is leveraging automation and advanced analytics to tackle #SDoH head-on. By harnessing technology, we're gaining deeper insights into state needs, streamlining interventions, and ultimately improving health outcomes. #HealthcareInnovation #DataDrivenHealthcare

18