Legislative Affairs Director Bill Eley has been busy creating summaries of federal legislation important to community pharmacy. These one-page descriptions of proposed legislation in Congress quickly and easily explain what is in each of the bills, and why they are important.

Here's what Bill has to say:

H.R. 244
“MAC Transparency Act of 2015”

H.R. 244 is a bipartisan bill that would ensure federal health plan reimbursements to pharmacies keep pace with generic drug prices, many which skyrocket overnight. The MAC Transparency Act of 2015 was introduced by Representatives Doug Collins (R-GA-09) and Dave Loebsack (D-IA-02) on January 9th, 2015.

Background

Though generic prescription drugs account for approximately 80 percent of drugs dispensed, the reimbursement system for these medications is largely unregulated and a complete mystery to pharmacists. Furthermore, the lack of transparency raises serious questions as to whether Medicare is overpaying drug plan middlemen, pharmacy benefit managers (PBMs). The contracts independent community pharmacies sign with PBMs in order to gain access to their pharmacy networks are non-negotiable and do not disclose the terms and conditions regarding payments for most generic drugs.

Pharmacists are often reimbursed for generics via Maximum Allowable Cost (MAC) lists created by the PBMs, but the methodology to create these lists are not disclosed, nor are the lists updated on a regular basis, frequently resulting in pharmacists being reimbursed below acquisition cost for various medications.

The MAC Transparency Act of 2015 will:

Increase transparency of generic drug payment rates in Medicare Part D, the Federal Employees Health Benefits program (FEHB), and TRICARE pharmacy programs, by requiring PBMs to:

• Provide pricing updates at least once every seven days;
• Disclose the sources used to update MAC prices; and
• Notify pharmacies of any changes in individual drug prices in advance of the use of such prices for the reimbursement of claims.
• Establish an appeals process to resolve disputes when drug prices are less than the acquisition cost of a drug

Expands the definition of a drug pricing standard.

• Definition specifically includes MAC as a pricing standard.

Protect patient privacy and choice of pharmacy in Medicare Part and FEHB pharmacy programs by:

• Prohibiting a PBM from transmitting personally identifiable utilization or claims data to a PBM-owned pharmacy, unless the patient has voluntarily elected to fill their prescription at such pharmacy; and
• Prohibiting a PBM from requiring that a beneficiary use a retail or mail order pharmacy in which the PBM has an ownership interest.

H.R. 793
“Ensuring Seniors Access to Local Pharmacies Act of 2015”

H.R. 793 was introduced by Reps. Morgan Griffith (R-VA-9) and Peter Welch (D-VT-At Large) on February 5th, 2015. The bill would allow community pharmacies that are located in medically underserved areas (MUAs), medically underserved populations (MUPs), or health professional shortage areas (HPSAs) to participate in Medicare Part D preferred pharmacy networks so long as they are willing to accept the contract terms and conditions that other in-network providers operate under.

Last Congress, this bipartisan legislation garnered 80 cosponsors: 43 Republicans and 37 Democrats. (Numbered H.R. 4577 in the 113th Congress).

HOW SENIORS ARE DENIED ACCESS AND SMALL BUSINESS IS BOXED OUT

Currently, many Medicare beneficiaries are effectively told by insurance middlemen (pharmacy benefit managers or PBMs) which pharmacy to use based on exclusionary arrangements between PBMs and, for the most part, Big Box pharmacies. Patients must pay higher copays if their pharmacy of choice is excluded from the preferred network. The majority of the time, the pharmacy is never given the opportunity to participate in the network in the first place.

Preferred networks were originally created to foster fair and increased competition, as well as save the federal government money. However, PBMs have refused to make their contracts transparent or public. Even in the taxpayer-funded Medicare Part D program, the federal government is left with just the assurance that these drug middlemen are saving beneficiaries and taxpayers money, rather than actual proof of savings.

EVEN MEDICARE QUESTIONS PREFERRED NETWORK SAVINGS

After conducting a recent study, Medicare officials concluded that even with the PBMs’ use of arbitrary and exclusionary pharmacy network contracting tactics, Medicare can no longer assume that preferred networks are less expensive for the government. They identified instances where such networks were in fact costlier to the program.¹ Moreover, a leading health care economist has demonstrated how allowing the participation of "any willing pharmacy" as a "preferred pharmacy" can actually lower Medicare costs by increasing competition.²

A SOLUTION FOR THE UNDERSERVED

H.R. 793 seeks to offer access to lower drug copays and healthcare services provided by local, community pharmacists to those seniors who need it most: the ones located in regions of the country that the Health Resources and Services Administration (HRSA) has defined as primary care physician shortage areas. A recent Medicare study found that in urban areas more than half of "preferred" pharmacy drug plans (54 percent) failed to meet the government's threshold for reasonable access to pharmacies.³ And in rural America, the closest "preferred" pharmacy can often be 20 miles or more away.

¹ Centers for Medicare and Medicaid Services. “Part D Claim Analysis: Negotiated Pricing Between Preferred and Non-Preferred Pharmacy Networks.” April 30, 2103.
² Eisenstadt, David M. “How H.R. 4577’s Any Willing Pharmacy Provision Could Leave Drug Prices Unchanged.” August 6, 2014.
³ Centers for Medicare and Medicaid Services. “Convenient Access To Retail Pharmacies – Analysis of Preferred Cost-Sharing Pharmacy Networks.” December 16, 2014.

H.R. 592
“Pharmacy and Medically Underserved Areas
Enhancement Act of 2015”

Reintroduced by Representatives Brett Guthrie (R-KY-2), Todd Young (R-IN-9), G.K. Butterfield (D-NC-1), and Ron Kind (D-WI-3) on January 28, 2015.

H.R. 592 enables Medicare beneficiaries access to pharmacist-provided services under Medicare Part B by amending section 1861(s)(2) of the Social Security Act to recognize pharmacists as providers.

• Pharmacist-provided services would be reimbursable under Medicare Part B only if they are provided in areas of the country that HRSA defines as medically underserved areas (MUAs), medically underserved populations (MUPs), or health professional shortage areas (HPSAs).
• The legislation does not expand services beyond each States’ already existing scope of practice.
• The legislation is consistent with precedent established by the Nurse Practitioners (NPs) and Physicians’ Assistants (PAs) provider status efforts; pharmacist services would be reimbursed at 85% of the physician fee schedule.

Millions of Americans already lack adequate access to health care due to primary care physician shortages in their communities, despite many of these patients having health insurance coverage. According to Congressional Budget Office estimates, an additional 36 million individuals may potentially gain health coverage under the Patient Protection and Affordable Care Act (PPACA), exacerbating the current shortage of physicians. The Association of American Medical Colleges projects that by 2020, there will be more than 91,000 fewer doctors than needed to meet demand.

KEY POINTS

• Pharmacists are capable of playing a greater role in the delivery of healthcare services. Pharmacists who practice at the fullest extent of their education, training, and license can provide services that include health and wellness screenings, chronic disease management, immunization administration, medication management, and working in and partnering with hospitals and health systems to advance health and wellness and reduce hospital readmissions.
• Enabling pharmacists to more fully utilize their education, training and expertise, and be more integrated into the patient’s health care team will also improve health outcomes and greatly benefit specific populations with chronic disease; including those with diabetes and cardiovascular disease.
• However, the lack of pharmacist recognition as a provider by Medicare limits payment for services provided by pharmacists, thereby limiting patients’ access to these essential services.
• These services are desperately needed in areas of the country that HRSA defines as medically underserved areas (MUAs), medically underserved populations (MUPs), or health professional shortage areas (HPSAs). Small, independent community pharmacies are often located in rural and highly-urban areas where larger, chain stores might not be as willing to locate. Community pharmacists can play an continually increasing and integral role in bringing access to care to those areas of the country, and beneficiaries, who need it most.
• In the 113th Congress, this popular and bipartisan legislation (then H.R. 4190) gathered 123 cosponsors: 68 Democrats and 55 Republicans.

S. 314
“Pharmacy and Medically Underserved Areas
Enhancement Act of 2015”

Introduced by Senators Chuck Grassley (R-IA), Sherrod Brown (D-OH), Mark Kirk (R-IL), and Bob Casey (D-PA) on January 29, 2015.

S. 314 enables Medicare beneficiaries access to pharmacist-provided services under Medicare Part B by amending section 1861(s)(2) of the Social Security Act to recognize pharmacists as providers.

• Pharmacist-provided services would be reimbursable under Medicare Part B only if they are provided in areas of the country that HRSA defines as medically underserved areas (MUAs), medically underserved populations (MUPs), or health professional shortage areas (HPSAs).
• The legislation does not expand services beyond each States’ already existing scope of practice.
• The legislation is consistent with precedent established by the Nurse Practitioners (NPs) and Physicians’ Assistants (PAs) provider status efforts; pharmacist services would be reimbursed at 85% of the physician fee schedule.

Millions of Americans already lack adequate access to health care due to primary care physician shortages in their communities, despite many of these patients having health insurance coverage. According to Congressional Budget Office estimates, an additional 36 million individuals may potentially gain health coverage under the Patient Protection and Affordable Care Act (PPACA), exacerbating the current shortage of physicians. The Association of American Medical Colleges projects that by 2020, there will be more than 91,000 fewer doctors than needed to meet demand.

KEY POINTS

• Pharmacists are capable of playing a greater role in the delivery of healthcare services. Pharmacists who practice at the fullest extent of their education, training, and license can provide services that include health and wellness screenings, chronic disease management, immunization administration, medication management, and working in and partnering with hospitals and health systems to advance health and wellness and reduce hospital readmissions.
• Enabling pharmacists to more fully utilize their education, training and expertise, and be more integrated into the patient’s health care team will also improve health outcomes and greatly benefit specific populations with chronic disease; including those with diabetes and cardiovascular disease.
• However, the lack of pharmacist recognition as a provider by Medicare limits payment for services provided by pharmacists, thereby limiting patients’ access to these essential services.
• These services are desperately needed in areas of the country that HRSA defines as medically underserved areas (MUAs), medically underserved populations (MUPs), or health professional shortage areas (HPSAs). Small, independent community pharmacies are often located in rural and highly-urban areas where larger, chain stores might not be as willing to locate. Community pharmacists can play an continually increasing and integral role in bringing access to care to those areas of the country, and beneficiaries, who need it most.

Click on the link listed below to download a PDF file of Bill's summaries.