William Sarraille’s Post

9 Reasons the #IRA #Medicare #Facilitator Guidance Is Sheer Madness (Part 2) My prior post gave reasons 1-5. Here are the rest! 6) No Concrete Plan on Adjustments: #CMS readily acknowledges that adjustments and reversals will be necessary, but it offers zero insight into how this will work: “CMS is considering how to address claim adjustments and reversals”. Well, that’s certainly a confidence builder. 7) 14 Day Prompt Pay Window: The cherry on top of this crazy sundae is the mandate that manus will have just 14 days from the receipt of #MTF data purporting to identify a “#fairprice” transaction to (1) make the price available on a retro basis, (2) confirm it was given prospectively, or (3) claim (with support) that the drug was #340b eligible. And, oh, by the way, the guidance threatens both “fair price” and 340B #CMPs if the manu gets either price wrong. So. Much. Fun. 8) The Ultimate Question Is Still Up in the Air: CMS adds to the uncertainty and its own indecisiveness by framing alternative visions as to how retro payments to get to the “fair price” might actually be made. How the “fair price” payments need to be undertaken is the ultimate question here, but CMS only offers two vague “options”—without committing to any clear answers. Option 1 is that the MTF gives provider and supplier banking info to the manufacturer and then dumps the payment mess on the #drug maker. This is a recipe for disaster, but CMS, already signaling that it is overwhelmed by the tasks in front of it, might take this easy way out—as it already has on the 340B de-dupe question. Option 2, clearly preferred by the stakeholders, is that the manu makes aggregate payments to the MTF and the MTF distributes those to the providers. But is CMS prepared to have its MTF, still not yet selected, take on this huge task? 9) The Clock Is Ticking: With it unclear how “fair price” payments will be made and all the other unanswered questions here, it’s not clear that the MTF can be successfully implemented in the 18 months left before D Day. Once the alternative retro payment models proposed in the guidance are evaluated and a decision made, there’s an awful lot to do in a dwindling amount of time. An MTF RFP has to be issued; the winning bidder has to be selected; the contracting has to be completed; the inevitable bid protest has to be litigated; and then the MTF has to be fully designed, implemented, and tested. All that and more must be accomplished in a time frame that grows a little more insanely short each day. You can tell CMS is getting worried because it repeats, over and over again, how it is the “manufacturers’ responsibility” to make the “fair price” available. That’s a tell. CMS is getting ready to redirect criticism of it onto “#Bigpharma”—when in doubt, go back to your go to message. Bottom line: the guidance is a source of real concern—not making this pessimist any less pessimistic.

FAQs for Practices 🙋🏽♂️ What are your invoice terms? We invoice on the last day of the month, and our terms are 14 days NET. #MedicalPractices #FAQs #invoiceterms #GPs #PracticeManager

With apologies to Stevie Wonder, ..."when you believe in things that you don't understand, then you suffer, regulation is the way." Not so superstitious, but many feel the traditional PBM model will not heal itself, so mandated legislative oversight will help move things along. Fortunately, there is no shortage of "new wave" PBM alternatives willing to lead the way into a transparent and pass-through promised land. The market is definitely moving. Let's see if this boat can be turned without a regulatory sledgehammer! #pbmreform #pbmregulation #pbms

The CAA brought to light the problem we’ve been trying to fix for decades: the pharmacy benefits industry is broken — and fiduciary standards are necessary to lay the groundwork for a better system. Download the white paper to learn how a fiduciary mindset minimizes pharmacy risk and maximizes savings: https://hubs.li/Q028-W6S0 Better Outcomes and Lower Cost. #whitepaper #fiduciary #pbm

#CMS Drop... Rerun of Payment Year (PY) 2017 "The deadline to submit all PY 2017 (2016 dates of service) deletions is 8:00 PM ET, Wednesday, July 31, 2024." "This memo is to notify Medicare Advantage (MA) Organizations, PACE Organizations, Medicare-Medicaid Plans, Cost Contractors, and any demonstration plans that submit risk adjustment data of the deadline for the submission of deletes in the upcoming rerun of Payment Year (PY) 2017...."

Wow. #340B was ~20% of #Medicare Part D claims in 2020, i.e., #BecauseOf340B, seniors & taxpayers : 1. overpaid for prescriptions that #hospitals bought for $0.01 2. funded #340B profits earned by covered entities & #PBM contract #pharmacies ==> https://drugch.nl/47HCCO0

Don't miss our webinar at 2:30pm where Christy Wilbert (SVP) is reviewing plan year 2025 CMS changes with Karen McDaniel (Compliance Director). In this final rule, we are focusing on current payment structures, including the use of administrative payments, among MA organizations and agents, brokers, and TMPOs, specifically FMOs, that may incentivize some agents or brokers to emphasize or prioritize one plan over another, irrespective of the beneficiary’s needs, leading to enrollment in a plan that does not best fit the beneficiary’s needs and a distortion of the competitive process.

Quite an interesting list for the first go-around. Will be interesting to see/hear what goes on over the next several months, both in the courts and with CMS. #cms #medicarepartd

HOW THE FIRST 10 DRUGS SET FOR MEDICARE NEGOTIATIONS WERE CHOSEN While the IRA requires CMS to select the drugs on which Medicare spends the most, experts said calculating annual expenditures is not a cut-and-dried process. Click the link below to read the full article.