Compromises help the Republicans pass a new version of the AHCA in the House. Learn more.

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May 5, 2017


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No (CBO) Score, No Problem: House Passes ACA Repeal-and-Replace Bill


President Trump’s campaign pledge to dismantle the Affordable Care Act (ACA) passed its first hurdle Thursday afternoon, as the House of Representatives passed a revised version of the American Health Care Act (AHCA) that would repeal and replace parts of the ACA. Passed by a slim 217-213 margin, the AHCA now heads to the Senate, where it faces an uncertain future. All House Democrats and 20 Republicans voted against the bill.

As Health Policy Weekly readers know, the original AHCA was withdrawn from consideration last month because it lacked the necessary votes for passage. Since then, 2 compromises garnered sufficient Republican votes from the moderate Tuesday Group and the conservative and libertarian Freedom Caucus:

  • MacArthur Amendment. An amendment offered by Rep. Tom MacArthur (R-NJ), co-chair of the Tuesday Group, helped win support from the Freedom Caucus. The amendment allows states to waive certain insurance rules and consumer protections required under the ACA, particularly those related to essential health benefits and community rating.
  • Upton Amendment. Rep. Fred Upton (R-MI) added an amendment that secured sufficient moderate Republicans by adding $8 billion over 5 years for individuals with preexisting conditions in states that make that request.

The revised legislation was brought to the floor even though it has not yet been scored by the non-partisan Congressional Budget Office (CBO). This is significant because this means that the legislation was voted on without knowing its estimated cost and what the impact will be on the number of insured individuals. The CBO did score the AHCA in its original form and estimated it would cause 24 million people to lose health insurance within a decade. The American Hospital Association has said it is unlikely the MacArthur amendment would improve the coverage estimates.

A timeline for consideration by the Senate is undetermined. If the upper chamber does take up the AHCA, makes changes, and passes a revised version, the standard process would be for a House-Senate conference committee to iron out differences. The Senate, with little room for defection from ACA repeal-replace legislation, has already indicated it will start over and likely will not use the House bill as the basis for its work. What this all boils down to is that healthcare reform is still under discussion and will be for a long time. The Senate, unlike the House, is not known for speed but rather deliberation. HPW staff thanks the Senate in advance for providing weeks of material to come.


Up, Up, and Away: Cost and Reimbursement of Air Medical Services


The Association of Air Medical Services (AAMS) commissioned Xcenda to conduct research on costs and payment adequacy for providing emergent air medical services. A detailed cost data collection tool was created and distributed to providers who volunteered to participate. Respondents represented 51% of all air medical bases nationwide and captured 46% of air medical services billed to Medicare.

Highlights of the study findings include:

  • The median reported cost of an emergent air medical transport is $10,199
  • On average, Medicare payment rates cover only 59% of actual costs
  • Over 1/3 of respondents reported negative margins for emergent air medical services

“A study such as this is long overdue,” says Rick Sherlock, AAMS President & CEO. “It has been AAMS’ position for some time that Medicare payments do not adequately match costs. The results of the cost study have validated our stance. The data provide a baseline for transport providers industry-wide regardless of business model.”


Money-Back Guarantee: Amgen and Harvard Pilgrim Ink Deal


Amgen and Harvard Pilgrim announced that they signed a first-of-a-kind contract whereby the manufacturer will fully refund the cost of Repatha® (evolocumab) if a patient is hospitalized with either a heart attack or stroke. However, the patient must have taken Repatha “properly” for at least 6 months before a cardiac event for Amgen to refund the treatment cost. In exchange, Harvard Pilgrim will lower the coverage restrictions for high-risk patients.

This is the second patient-focused outcomes contract Harvard Pilgrim has negotiated with Amgen for Repatha. In November 2015, the health plan signed an outcomes guarantee through which Amgen provided the insurer with an enhanced discount if the reduction in low-density lipoprotein (LDL) levels for Harvard Pilgrim members is less than what was observed during Repatha’s clinical trials.

Harvard Pilgrim has been active with innovative deals. In February, it signed an outcomes-based contract with Amgen for Enbrel® (etanercept) based on therapy effectiveness and a value-based contract with Eli Lilly for Forteo® (teriparatide), which will measure patients’ adherence.

Value- and outcomes-based contracts are becoming more common, and the groundbreaking refund contract may offer manufacturers and insurers another option. Insurers are already concerned with how to pay for personalized medicine, as drugs are likely to become more expensive as the patient pool shrinks. Challenges like data capture and best-price implications are often the sticking points. But the Amgen-Harvard Pilgrim type of guarantee contract could prove palatable to both groups of stakeholders and show a path forward for these types of contracts.


Pressure Points: Patient Groups Want Expanded Access to Products


Earlier this week, patient advocate organizations supporting increased access to experimental drugs published a joint Summary of Principles for policy-makers to consider. These advocate groups are seeking to establish clear standards and criteria for patients who are not participating in clinical trials to have access to unapproved therapies.

Key items in their Summary of Principles include:

  • An expanded role for the Food and Drug Administration (FDA) to promote broadening of clinical trial inclusion criteria  
  • Establishment of ethical standards and protections for patients
  • Creation of Institutional Review Boards to manage requests and provide oversight
  • Guidelines for sponsors of experimental drugs and unapproved therapy and to include, among other things, public access to policies and contact information

Patient groups supporting this stance include the Alliance for Aging Research, American Cancer Society Cancer Action Network, Friends of Cancer Research, Leukemia and Lymphoma Society, National Organization for Rare Disorders, Parent Project Muscular Dystrophy, and St. Baldrick’s Foundation.

Commonly referred to as "Right-to-Try," 33 states have now passed legislation addressing various aspects of access to unapproved therapies. Recently introduced "Right-to-Try" bills are now being considered by the US House and Senate, S.204 and H.878.   

The 21st Century Cures Act may advance the cause of the advocates more than anything else, as section 3032 requires pharmaceutical manufacturers to be more transparent about how they decide who gets experimental access to promising medications and how long it will take.


Information Buffet (AKA, Other Stuff That Caught Our Attention)


We kept running into stories we wanted to bring to your attention, so here’s a quick hit list of other news we thought you should know:

  • Gotcha!: The National Coalition on Health Care launched a spoof drug ad as part of its multimillion-dollar Campaign for Sustainable Rx Pricing.
  • What’s a week without ICER?: The Institute for Clinical and Economic Review (ICER) has delayed the posting of its updated Value Assessment Framework until late May 2017 “due to the volume and comprehensiveness of the comments and suggestions received on the proposed changes.”
  • Party time: The Department of Health and Human Services announced a June 5 meeting of the Physician-Focused Payment Model Technical Advisory Committee.
  • Maybe something good, maybe something bad: The California insurance commissioner has asked insurers to file 2 sets of premium requests for 2018 to account for uncertainty about the future of the ACA
  • A PBM-shaped hurdle: A Community Oncology Alliance white paper “exposes delay, waste, and cancer treatment obstacles imposed on patients by pharmacy benefit managers (PBMs)”

FDAMA 114 and the 21st Century Cures Act: Insights From Payers and Manufacturers, and Implications for the Exchange of Health Care Economic Information


ISPOR 22nd Annual International Meeting
May 20–24 l Boston, MA

Join Xcenda’s Jay Jackson, PharmD, MPH, Senior Vice President of Scientific Consulting, as he moderates a Tuesday lunchtime symposium titled, “FDAMA 114 and the 21st Century Cures Act: Insights From Payers and Manufacturers, and Implications for the Exchange of Health Care Economic Information,” at the ISPOR 22nd Annual International Meeting in Boston May 20–24. Visit us at booth #817 to meet with our global HEOR team and learn more about our award-winning research.

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“Today we made history by taking the first important step toward rescuing hardworking families from the failures and skyrocketing costs of Obamacare.”

– House Majority Whip Steve Scalise (R-LA), in a statement on the passage of the AHCA


“@HouseGOP either does not know the consequences of passing #Trumpcare, or they do not care, or both.”

– House Democratic Leader Nancy Pelosi (D-CA), in a tweet on the passage of the AHCA




Rejection rate for PCSK9 inhibitor claims for managed care organizations across the nation from July 30, 2015 to July 21, 2016. Of national health plans that received at least 1,000 claims for PCSK9 inhibitors, the following had the highest rates of rejection:

  • Federal Employee Benefit Plan: 85%
  • Express Scripts: 62%
  • Anthem: 62%
  • Cigna Healthcare: 51%

Source: “Health Plans Nationwide Reject 43% of Claims for High Cholesterol Treatment,” Alliance for Patient Access, April 27


ISPOR 22nd Annual International Meeting

May 20–24 l Boston, MA
Join Xcenda’s Jay Jackson, PharmD, MPH, Senior Vice President of Scientific Consulting, as he moderates a Tuesday lunchtime symposium titled, “FDAMA 114 and the 21st Century Cures Act: Insights From Payers and Manufacturers, and Implications for the Exchange of Health Care Economic Information,” at the ISPOR 22nd Annual International Meeting in Boston May 20–24. Visit us at booth #817 to meet with our global HEOR team and learn more about our award-winning research. Learn more


2017 ASCO Annual Meeting

June 2–6 l Chicago, IL
Join leaders and experts from AmerisourceBergen at ASCO’s Annual Meeting in Chicago. This meeting brings together more than 30,000 oncology professionals from around the world to discuss state-of-the-art treatment modalities, new therapies, and ongoing controversies in the field. Visit AmerisourceBergen’s booth at #6135. Learn more


HDA 2017 Business and Leadership Conference

June 11–14 l Phoenix, AZ
HDA’s Business and Leadership Conference (BLC) is the healthcare distribution industry’s signature annual conference. The conference brings together high-level executives and influencers across the healthcare supply chain to hold strategic business discussions on the industry’s most pressing issues. AmerisourceBergen’s John Wernicki, Senior Director of Strategic Accounts, will join a panel titled, “Ask the Distributors: How Personalization Works,” on June 12 from 11:45 AM–3:30 PM to provide tips on how to help the independent pharmacy channel grow its front end and drive a more profitable business mix. Learn more


2017 BIO International Convention

June 19–22 l San Diego, CA
Join experts from World Courier and Xcenda at the 2017 BIO International Convention in San Diego. This annual conference, hosted by the Biotechnology Innovation Organization (BIO), is the largest global event for the biotechnology industry and attracts the biggest names in biotech. Visit the World Courier booth at #5408. In addition, Jennifer Snow, MPH, Director of Health Policy at Xcenda, will participate on a panel titled, “The Whole Picture: Consideration of Personalized Medicine in Value Assessment Frameworks” on June 22 at 10:15 AM PT. Learn more


2017 Pharmaceutical End-to-End Supply Chain Management Summit

July 24–25 l Philadelphia, PA
Matt Sample, Senior Director, Secure Supply Chain at AmerisourceBergen, will present, “Utilize Serialization and Traceability Data to Ensure End-to-End Supply Chain Visibility.” He will discuss standardized product packaging and serialization, show how to integrate data standards within the commercial supply chain for enhanced visibility, and review the methods to secure the data and ensure interoperability throughout the end-to-end supply chain. Learn more


Count on Health Policy Weekly for an at-a-glance view of legislative and regulatory developments and news that impacts the healthcare industry.


Jennifer Snow
Health Policy

Scott Shields
Associate Director,
Health Policy



Peyton Howell, MHA
President | Global Sourcing & Manufacturer Relations | AmerisourceBergen Corporation

Amy Grogg, PharmD
Senior Vice President | Strategy & Commercialization | AmerisourceBergen Specialty Group

Tommy Bramley, PhD, RPh
President | Xcenda

Stacie Heller
Vice President | Government Policy | AmerisourceBergen Corporation

Rita Norton
Senior Vice President | Government and Public Policy | AmerisourceBergen Corporation

Ana Stojanovska
Vice President | Reimbursement & Policy Insights | Xcenda


Bernard Falkoff | Marla Kugel | Scott Shields | Stephen Wilson


Kylie Matthews | Ellen Olson


May 5, 2017


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