Expert Discusses Updates in Reimbursements, Pharmacy Benefit Manger Reform

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Ronna Hauser from the National Community Pharmacists Association (NCPA), discusses updates regarding reimbursement, pharmacy benefit manager (PBM) reforms, and direct and indirect remuneration (DIR) fees.

Pharmacy Times spoke with Ronna Hauser, senior vice president of policy and pharmacy affairs at the National Community Pharmacists Association (NCPA), about updates regarding reimbursement, pharmacy benefit manager (PBM) reforms, and direct and indirect remuneration (DIR) fees.

Q: Can you provide an overview of the current landscape of reimbursement issues that pharmacists are facing, and how they impact community pharmacy practice?

Ronna Hauser: Our members, the independently on community pharmacies, are facing many pressures related to reimbursement for the drugs they dispense, primarily, the federal government programs, Medicare and Medicaid take up a very large portion of their business pursuant to the number of prescriptions they dispense. So we at NCPA worked very hard to make sure that payment reforms in Medicare and Medicaid make it across the finish line. We have a lot of momentum behind us right now with this Congress, and some very active legislation that would reform how pharmacies are paid for the prescriptions they dispense in both Medicaid managed care programs and Medicare Part D. At the end of the day, there is a lot of concern in the industry right now, especially with the new rules that go into effect in 2024 for Part D. There could be some severe cashflow concerns for our members in the new year. We're trying to do all we can to rectify those concerns and make sure that we're reforming the pharmacy payment model.

Pharmacy Interior | Image Credit: Tyler Olson - stock.adobe.com

Tyler Olson - stock.adobe.com

Q: What role do pharmacy associations and advocacy groups play in addressing reimbursement issues, DIR fees, and PBM-related concerns, and how can pharmacists become more involved in these efforts?

Ronna Hauser: NCPA is the voice of the community pharmacist, we work very hard day in and day out on Capitol Hill, and with the federal government agencies, and also at the state level, to represent our members and make sure they're able to stay in business and thrive and help their communities. I would say that as a national trade association, that's our number one priority is to advocate for the voice of our members each and every day in Washington DC. That goes beyond inside the beltway; it goes out to the state level as well, where reforms are vitally important, I would say as an independent pharmacy owner, it's very important to be engaged at the national level as well as the state level in the future of your profession. NCPA makes it very easy to be engaged. We have a legislative action center. We encourage all of our members to sign up to receive alerts from our legislative action center, and when something is about to move, or something is very important that our members need to weigh in with their elected officials, we will make sure and put those legislative call to actions out and usually all it takes is a few click throughs to sending a very important note to our members and elected officials. Hopefully, we can encourage passage of legislation that will be beneficial to independent pharmacies and most importantly, our patients.

Q: Can you speak on some of the initiatives that NCPA is currently working towards for reimbursement and PBM reform?

Ronna Hauser: There are active legislative packages moving through Congress moving, through Washington DC, right now pertaining to [PBM] reform, and also pertaining to how pharmacy reimbursement works. Number 1 priority is to reform Medicaid Managed Care Program payments to pharmacies; we're working very hard to ban spread pricing once and for all and ensure that PBMs are paid an administrative fee for the job they do, and that pharmacies are paid transparently and fairly for the prescriptions they dispense. Number 1 priority is Medicaid Managed Care Reform, bans for pricing, payer members fairly based on acquisition costs, plus their cost to dispense. Then, number 2, major reform priority is Medicare Part D, and how Medicare Part D plans pay pharmacies for the prescriptions they dispense. Similarly, to our Medicaid managed care fight, to ensure that those payments are reasonable and relevant, they’re commensurate with the cost to acquire and dispense the drug. It's all about reforming the pharmacy payment model, and we're fortunate that they're active reforms right now on the move related to both Medicaid managed care and Medicare party.

Q: New York has announced a proposed regulation to increase the oversight of PBMs. What are the implications of this bill and how could it potentially impact community pharmacies?

Ronna Hauser: We're very supportive of what our members have been able to achieve in New York state. Many of the reforms that are working themselves throughout the regulatory process had been passed in other states, again, very important payment reforms and PBM reforms that we hope to see make it across the finish line. We all know that things change quickly, and things can change on a dime. We did hear some unfortunate news, I think, just as of yesterday, that maybe some of those regulations had been pulled back. We may end up with more of a PBM registration and licensure reform in New York State at this time, but we're monitoring that situation closely and making sure we understand what's happening on the frontlines there in New York State, but at the end of the day, they worked very hard to just get some common sense PBM reforms across the finish line that we’ve seen other states achieve as well.

Q: Are there any other pieces of legislation on the horizon that pharmacists should be aware of?

Ronna Hauser: I think in general, one area that we follow very closely, is related to pharmacists’ services and payment for those services coming out of COVID. Our members have done a heroic job with their vaccines services, related-services, with COVID therapeutics, etc. We really hope to see a lot of those authorities expanded and actually memorialized at the state level. We're working very diligently at the state level to make sure those authorities can extend into infinity, so that our members do have the authority to take care of their patients and get paid for the important services they're providing.

Q: Additionally, an independent pharmacy has filed a lawsuit against various health care entities in regard to DIR fees. What could the implications of this lawsuit have on the pharmacy industry as a whole?

Ronna Hauser: It's important to know that this is a backward-looking effort to clawback ill-gotten fees that CVS took in violation of the law. We would hope that such an action would change CVS’s behavior, again, but we expect it to be a long hard-fought battle in the courts, and if successful, it might keep a few more pharmacies open and protect the vital infrastructure that gives patients choice access and quality to pharmacy services and pharmacy care.

Q: What are the expected timelines and next steps in the legal proceedings for this class action lawsuit, and what can we expect in the near future regarding this case?

The class action lawsuit is expected to take years that's why NCPA has created a parallel track that might bring relief much sooner. Anyone that's listening can find out more about it, and we've created a website to learn more about this effort. It's fightpbms.com. Take a look at that website and learn more about a parallel track effort that's been undertaken for independent pharmacy.

Q: There has been gathering momentum among legislators to address theses challenges surrounding the actions of PBMs, reimbursements, and DIR fees. How could the independent pharmacy lawsuit potentially help to accelerate the needs for reform in this area?

Ronna Hauser: I think it's just NCPA fights hard at all levels. We fight for legislation at the federal and state levels that will impact our profession in the most positive manner possible. We fight at the administrative level, so with the agencies that put forth regulations that impact our industry. Then if that fails, and we can't have success, or we need relief sooner, we'll absolutely go to court and fight on our members behalf, so that's what we've undertaken here. Again, it's a backward-looking effort that looks to, again, clawback fees that were ill assessed on our members. So that's just one piece of the puzzle. As I mentioned earlier, what we're really fighting for is to change the pharmacy payment model and make sure payments are reasonable, relevant, cover the cost to acquire drug, and cover the cost to dispense the drug. We always will have a multi-pronged approach here at NCPA and will continue down that track.

Q: Finally, what advice do you have for pharmacists dealing with reimbursement challenges, DIR fees, and PBM-related issues to navigate these complexities and maintain a thriving pharmacy practice?

Ronna Hauser: It gets back to being engaged: be engaged at the state and federal level, understand changes that may be coming that are going to impact your business. Again, we put forth as much information and education as we can. Be prepared is the most important advice I can give. I mentioned changes that are going to go into effect in Part D starting January 1. We do have some concerns, again, that there could be cashflow concerns for our members were concerned about their businesses and their patients. So be prepared, make the changes you need to within your business to be able to succeed and to grow. I think there's a lot of opportunity out there. We do see a lot of positive signs pointing in the future here and working diligently to try to get some commonsense reforms passed at the federal level this year.

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