LTC Pharmacy News

May 2024

While April kept us busy reviewing all the regulations coming out of CMS, May is a bit less hectic. This month the Medicare Trustees reported on the fiscal solvency of the program, while Omnicare Las Vegas employees voted to join a labor union. As usual, politics dominated the headlines as President Biden and Donald Trump rattle swords in the big battle for the White House in November,

May is, most notably, the time we turn our grateful thoughts to those brave men and women who have given their lives in defense of our nation. On Memorial Day, let's take the time to remember them.


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Federal News and Updates
CMS Announces Enrollment Figures for Medicare, Medicaid, and ACA
CMS reports that nearly half the US population receives healthcare services from Medicare, Medicaid and Affordable Care Act programs. Medicaid enrollment spiked during the pandemic, when eligibility was expanded, and the aging population has increased Medicare participation. More

Medicare Trustees Cite Improved Medicare Outlook
The Medicare Trustees issued their mandatory annual report to Congress with news that the program's solvency has been extended five years, to 2036, thanks to economic growth and lower-than-expected hospital and home health agency costs.

Justice Department Forms Task Force on Healthcare Monopolies
The Department of Justice announced the formation of a task force withi's solvenn the antitrust division that will target healthcare monopolies and their potential for collusion. Among the targets of this investigative effort are the PBMs, increasingly under attack for rising costs and reduced access to essential healthcare services.

Senate Finance Releases Discussion Draft on Drug Shortages
The continuing problem of critical drug shortages has captured the interest of the Senate Finance Committee, which has issued a discussion draft on potential legislation targeting GPOs, and requiring minimum contracts and sourcing contingencies,

Part B Drugs Payment Limit Primer
In the event you have forgotten the details of Medicare Part B drug payment limits, check out this handy primer on the dizzying array of computations that go into establishing these limits, courtesy of CMS.
What's Happening in the States
Oregon Physician Assistants Get a New Title
The Governor of Oregon signed legislation that changes the title of physician assistants. Not all PAs like it very much. More

State Actions on PBMs
Arizona:  Legislature passed Senate Bill 1165 and governor signed the bill. This measure prohibits a pharmacy benefit manager (PBM) to directly or indirectly retroactively reduce the amount of a claim payment to a pharmacist or a pharmacy after adjudication of the claim if a PBM is conducting an audit of the pharmacy, unless the original claim was fraudulent, duplicate, or incorrect.

Idaho:  Governor signed House bill 596: This measure prohibits a pharmacy benefit manager (PBM) to conduct spread pricing and requires a PBM to pass along 100% of manufacturer rebates to an insurer. A PBM shall provide full disclosure of the costs, prices, reimbursements, fees, markups, and discounts associated with the PBM's contract with a health plan, payer, or pharmacy, as well the aggregate amount of rebates received by the PBM from manufacturers.

IndianaHouse bill 1259 signed by governor: This measure amends existing legislation on the auditing of a pharmacy benefit manager (PBM) by an entity with which the PBM has contracted. A contract holder may require full disclosure of claims received by the PBM, claims payments provided by the PBM, and any other revenues and fees collected by the PBM under the contract, including all direct and indirect renumeration from pharmaceutical manufacturers regardless of whether the renumeration is classified as a rebate, fee, or other term.

Kentucky: House bill 190, signed by governor:  This measure establishes that the minimum reimbursement for the cost of a drug that existing law requires a pharmacy benefit manager (PBM) to pay shall not apply to a pharmacy with a designated pharmacy type of "retail chain" until the commissioner has determined reimbursement for a professional dispensing fee beginning on or after January 1, 2027, as directed by existing law.

OregonHouse bill 4012: This measure prohibits a health insurer or pharmacy benefit manager (PBM) to require an enrollee to obtain a covered clinician-administered drug from a pharmacy selected by the insurer or PBM, steer an enrollee to obtain a clinician-administered drug from a specific pharmacy, or assess higher cost-sharing amounts for clinician-administered drugs obtained from a pharmacy that is not selected by the insurer or PBM.
Everything Else
Google's Med Gemini Said to Surpass GPT-4 
Google announced that its Large Multimodal Model AI product outdoes GPT-4 on popular benchmarks, overcoming Large Language Model (LLM) shortcomings on responding to medically-based prompts. More

Optum's New Pricing Model: More Predictability and Transparency
Optum Rx, a major PBM, is introducing a new option for its clients, beginning in January. Dubbed Optum Rx Clear Trend Guarantee, the new offering consists of providing a single per member cost, including home delivery, pharmacy, and specialty drug rebates in a single guarantee. The Clear Trend Guarantee will be offered alongside the Cost Made Clear program. More 

Medigap Policies Continue to be Popular Among Medicare Enrollees
When signing up for Medicare, enrollees can choose between traditional coverage with supplemental (Medigap) policies, or Medicare Advantage (managed care). Despite the recent popularity of Medicare Advantage, more beneficiaries are choosing traditional coverage with Medigap. More

KFF: Up To One-Fourth of Medicare Beneficiaries With Obesity Could be Eligible for Wegovy Injections
KFF (formerly Kaiser Family Foundation) finds that 3.6 million people with Medicare could be eligible for coverage of Wegovy (semaglutide) now that the Food and Drug Administration has approved the use of the anti-obesity drug to reduce the risk of heart attacks and stroke in certain patients. More

Walmart Shutters Retail Care Clinics
An innovation that was intended to disrupt primary care has come to a halt at Walmart, as the company decided to close all its 51 Walmart Health centers. Walmart executives concluded the current model was not sustainable for the company, due to high care costs and unprofitable reimbursement. More

CVS Hit by Higher Medicare Advantage Costs and Change Healthcare
Healthcare powerhouse CVS reported higher costs associated with the cohort of Medicare Advantage enrollees in its plans, and increased costs associated with RSV-related claims. The impact of the Change Healthcare cyberattack also caused the pharmacy giant to create a $500 million reserve for unpaid claims. More

Employers Play Hardball With Healthcare Providers
What do you do when your OB/GYN network provider group let's you know prices are going up by 35 percent? If you're the Miami Dade School District you tell them goodbye! The docs crawled back later, suggesting a more reasonable 5 percent hike. Apparently, some employer groups are not considering provider demands for increased payments to be business as usual. More

How You Spend Your Time: Differences by Age Cohort
It makes sense to say that competition for your time changes as you go through life. See how different age cohorts spend their allotted 24 hours. How different are you than your contemporaries? More

Las Vegas Omnicare Pharmacy Votes to Unionize
By a vote of 26-4 Omnicare employees at the Las Vegas pharmacy voted to join the Pharmacy Guild, a new labor union. The union has other organizing efforts underway around the country. More

ASCP CEO: Revolutionizing Long-Term Care
ASCP Chief Chad Worz looks at the state of long-term care and thoughtfully considers what lies ahead. If you care about LTC and LTC Pharmacy, this is a must-read. More