The recent bipartisan agreement to fund the federal government includes several important provisions for healthcare, with significant reforms aimed at pharmacy benefit managers (PBMs) at the forefront. PBMs, often seen as controversial middlemen in the drug supply chain, will face new regulations if the stopgap funding bill is passed.
One of the key reforms in the bill is the requirement for PBMs to pass through 100% of rebates to sponsors of prescription drug plans in Medicare and the group health market. This change aims to eliminate the practice of rebate retention, which could incentivize drugmakers to increase list prices. By passing through rebates, PBMs would be required to provide more transparency in their financial practices.
While these reforms have been praised by pharmacist groups, patient advocates, and lawmakers seeking to lower drug costs, there are concerns about whether the changes will actually benefit patients in the long run. Critics argue that the reforms may not necessarily reduce costs for patients and could have unintended consequences.
In addition to PBM reforms, the funding bill also includes provisions to prevent payment cuts in Medicaid to hospitals serving vulnerable patients, extend Medicare programs for rural healthcare access, and increase funding for community health centers. The bill also addresses issues such as “ghost networks” in privatized Medicare plans, protecting beneficiaries from unexpected costs.
The PBM reforms in the bill have been described as historic, as they would significantly impact how PBMs operate in the healthcare system. PBMs would no longer be allowed to link their payments to drug prices in Medicare, and they would be required to pass through rebates to plan sponsors. The bill also prohibits spread pricing in Medicaid, requiring PBMs to reimburse pharmacies the full cost of drugs plus a dispensing fee.
Overall, the new regulations aim to increase transparency and accountability in PBM practices, providing more clarity to clients and regulators. While the reforms are seen as a positive step towards addressing rising drug costs, there are concerns about the potential impact on premiums and access to medications. The bill represents the first meaningful PBM reform from Congress and could have far-reaching implications for the pharmaceutical industry and healthcare system as a whole. The proposed legislation making its way through Congress is set to have a significant impact on the healthcare industry, particularly in the realm of pharmacy benefit managers (PBMs). Independent pharmacies, which have long pointed to PBMs’ tactics as a driving force behind pharmacy closures nationwide, are likely to benefit from the reforms outlined in the bill.
Lawmakers focused on PBM reform have praised the legislation, with Senate Finance Committee Chair Ron Wyden emphasizing the importance of shifting the healthcare system to favor seniors and families over big corporations and middlemen. Stocks in major PBM companies such as CVS, UnitedHealth, and Cigna have already taken a hit in anticipation of these policy changes, with President-elect Donald Trump adding fuel to the fire with his recent comments about “knocking out the middleman.”
The three major PBMs – Caremark, Express Scripts, and Optum Rx – have come under scrutiny for their business practices, including the collection of rebates that could be inflating drug prices. The Federal Trade Commission even filed a lawsuit against these companies in September. Analysts believe that while the proposed reforms may not be overly drastic, they could still have a significant impact on the way PBMs operate.
In addition to PBM reform, the legislation also includes extensions for telehealth coverage in Medicare for another two years. This move has been welcomed by telehealth advocates and providers who have been pushing for these flexibilities to continue, especially in light of the looming deadline for expiration. The extension of telehealth Medicare flexibilities will allow patients to receive care in their homes and even allow for some non-mental healthcare services to be offered through audio-only phone calls.
Telehealth groups have expressed their gratitude for the extension, noting that expanded virtual care options increase access to care, particularly for mental health services and patients who face long travel times to healthcare facilities. The temporary nature of these flexibilities can, however, pose challenges for smaller practices looking to invest in virtual care.
Furthermore, the legislation includes an extension of the CMS’ Acute Hospital Care At Home program for five years. This initiative, first enacted during the pandemic to boost hospital capacity during COVID surges, allows approved Medicare-certified facilities to provide inpatient level care in patients’ homes. Without congressional approval, this program was set to expire at the end of the year, potentially leaving hundreds of hospitals without this critical resource.
Lastly, the stopgap funding bill provides some relief to physicians by reducing a scheduled Medicare funding cut for next year to 0.3%, down from the originally approved 2.8%. Physician groups have long been advocating for a permanent fix to this situation, calling for annual reimbursement hikes to be tied to a measure of inflation. While the legislation falls short of fully addressing this issue, it does offer some respite to doctors facing financial strain.
Overall, the proposed legislation represents a step towards a healthcare system that prioritizes patients and providers over profit-driven middlemen. With reforms to PBMs, extensions for telehealth coverage, and support for physicians, this bill has the potential to bring positive change to the healthcare landscape.
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This content can be seamlessly integrated into a WordPress platform by creating new posts or articles based on the rewritten content. The World Health Organization (WHO) has declared the coronavirus outbreak a global health emergency, as cases continue to rise across the globe. With the number of confirmed cases surpassing 100,000 and the death toll climbing, governments and health organizations are taking drastic measures to contain the spread of the virus.
The coronavirus, officially named COVID-19, is a respiratory illness that originated in Wuhan, China. It is believed to have originated in a seafood market where live animals were also sold, leading to speculation that the virus may have been transmitted from animals to humans. The virus is highly contagious and spreads through respiratory droplets when an infected person coughs or sneezes.
As the virus continues to spread, countries around the world are implementing measures to prevent further transmission. Travel restrictions, quarantines, and cancelation of large public gatherings are some of the steps being taken to contain the virus. In China, where the outbreak originated, strict measures such as lockdowns of entire cities and mandatory quarantines have been put in place to prevent the spread of the virus.
Health organizations are urging the public to practice good hygiene to prevent the spread of the virus. This includes washing hands frequently with soap and water, covering coughs and sneezes with a tissue or elbow, and avoiding close contact with people who are sick. Face masks are also recommended for those who are sick to prevent the spread of the virus to others.
While the majority of cases are mild, the virus can be severe in some cases, especially in older adults and those with underlying health conditions. Symptoms of the virus include fever, cough, and difficulty breathing. If you develop symptoms and have recently traveled to an affected area or have been in close contact with someone who has been diagnosed with COVID-19, it is important to seek medical attention immediately.
As the situation continues to evolve, it is important to stay informed and follow the advice of health authorities. By taking proactive measures to prevent the spread of the virus, we can help protect ourselves and others from the potentially deadly consequences of COVID-19. Let us all work together to contain the outbreak and protect the health and safety of our communities.
