In the DC area, with many family, friends and neighbors working for the federal government, these last few weeks have felt downright crappy. Furloughs, contracts being upended, fear about what’s next — all for people who love their jobs serving the public. It isn’t a fork in the road, it feels like a game of Boggle with the constant scramble of the game. I was fortunate to take a step back last week and spend a lot of time outside. This week I was cautious about what caught my eye; there is only so much energy we have to spend. Hopefully I can treat you to the highlights …
Professional Jealousy. The National Pharmaceutical Council released a paper on the patient and caregiver journey for Cell and Gene therapies. The main graphic is *chef’s kiss*; it walks through the challenges facing patients and caregivers for these unique treatments. I wish I had done it myself.
More Cell and Gene. The New England Journal of Medicine had an article about the Center for Medicare and Medicaid Innovation (CMMI) sickle cell disease demonstration. If you’ve been meaning to catch up, here’s your chance.
A Moment to Opine. Ultimately the BIG question is how do we pay for more expensive treatments. I think we need a fourth way beyond consumers, plans and manufacturers — a Medicare Part E or some type of fund that plans pay into and/or is partially funded by the government. This story from STAT news this week about a 12 year old who will no longer have access to a $500k+/year medicine for seizures is heart-breaking. The manufacturer is currently paying for it but that is ending and plans do no want to pay for the drug. Super simple but let’s say the family’s premiums are $20k a year — that’s a lot of families not using their benefits to get to $500k to pay for the medicine. Now their are things like stop-loss insurance for the plan but it might not cover an off-label drug and, even if it did, ultimately, someone is paying for the drug. Generics are coming but they are expected to be hundreds of thousands of dollars as well. We need a better way of coverage and access to these treatments.
Yikes. In a letter to the Centers for Medicare & Medicaid Services (CMS), the National Community Pharmacists Association warned that more than 90% of independent pharmacies may or have decided, to not stock drugs that are part of the Medicare Drug Price Negotiation Program.
The issue is cash flow. Pharmacies will be purchasing the drug at their usual prices and then wait to be reimbursed by the plans but also by manufacturers. While there is a 14-day turnaround for manufacturers to pay pharmacies, NPCA believes pharmacies will likely be waiting over 30 days for payment and will have to float over $27,000 every month. With pharmacies already under pressure from pharmacy benefit managers (PBMs), there isn’t much wiggle room for pharmacies. The NPCA survey is publicly available.
No Real Guesses. As a health policy professional, I’ve been repeatedly asked to discuss my predictions for the next four years and I’m reluctant to say much. I think we might know more soon but Medicare and Medicaid don’t seem like a priority for RFK Jr. (snarky, I know.) That being said, there are certain realities (physician payments, Inflation Reduction Act negotiations, Affordable Care Act subsidies) that, as an article in JAMA points out, will likely be dealt with.
