Breaking news: Get a sneak peek at a leaked copy of the Republicans’ replacement for the ACA.

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Feb. 24, 2017


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Leaked Copy of GOP’s Replacement for ACA Sheds Some Light


A leaked copy of the Republicans’ replacement for the Affordable Care Act (ACA) has surfaced.

The proposal would remove the subsidies for Marketplace consumers and the law’s taxes. Instead of the Exchange subsidies, individuals would receive tax credits based on age, not income. For someone under age 30, the credit would be $2,000. That credit amount increases to $4,000 for those over the age of 60.

The heavily federally subsidized Medicaid expansion program would be reversed in 2020; states would still have the option to cover those enrollees, but the level of federal support is unclear. Additionally, the federal government would cap Medicaid payments to states, based on the size of the Medicaid population.

Other provisions include providing states “innovation grants” to cover the cost of expensive enrollees, and capping employers’ tax exemption for health insurance at the 90th percentile, with the amount above being used to offset the costs of the health reform.

The draft bill will undergo changes as Congressional leaders and the White House address details. We will continue to bring you coverage and analysis of the draft bill and its path through the House, Senate, and White House.


Recess, Meet Headache: Republicans Welcomed Home With Rowdy Town Halls


With Congress out on recess, many Republicans were met with rowdy crowds and protests in their ordinarily sedate town halls. Constituents voiced their concerns about the Trump Administration’s actions and questioned their Republican elected officials on topics ranging from healthcare to immigration to climate change. One of the hot topics was the GOP’s plan to “repeal and replace” the ACA.

In Mariposa, California, Republican Rep. Tom McClintock met with close to 1,000 constituents for a town hall described by the Capital Public Radio news as “opinionated yet peaceful, though manners and tempers sometimes ran short.” When asked about how the Trump Administration was going to keep healthcare affordable for the people who rely on the ACA, McClintock responded, “There’s no question that some people had a very good experience with the ACA, with Obamacare. But most people had a very bad experience with it.” The crowd reacted with a mix of support and disapproval. McClintock said Congressional Republicans are working on a plan that “supports health savings accounts, opening up insurance plans across state lines, and gives Americans refundable tax credits to purchase the plan that best meets their needs.”

Rep. Tom Reed (R-NY) also faced tough crowds during his town halls, as NPR reported. Although Reed voiced his support for the more popular provisions in the current ACA (eg, guaranteeing insurance coverage for those with pre-existing conditions and allowing children to remain under their parents’ insurance until age 26), his responses were not specific enough for some. One woman yelled, “We’re not comfortable with this until you tell us what you’re going to do, point by point, to replace our health care.”

While President Trump’s reaction to the recent influx of boisterous Republican town halls was to accuse liberal activists of purposefully planning the disruptions, seasoned Senator Chuck Grassley (R-IA) responded in stride. As The Des Moines Register reports, Grassley’s first town hall “was a raucous, sweaty tumult of cheering and jeering, interruptions and shouted questions,” but Grassley responded afterward that “he wouldn’t do his job any other way.”

As most of us recall back in 2009, a similar story of rowdy town halls during a Democratic Congress eventually helped lead Republicans to victory in the 2010 election. Now that the script has flipped, will history repeat itself in 2018?


Note from the Editor: We all have days when we take our work home with us. But sometimes our home follows us to work. One of our associates, Diane Wilson, serves in a volunteer capacity as an active Emergency Medical Technician at the Fort Edward Rescue Squad. With her service area located in upstate New York along the 1-87 corridor, the severity of the opioid epidemic becomes her reality while on duty. We are inspired by her work and wanted to bring her home to your work.


Third Time, Not Always a Charm


By Diane Wilson, Xcenda

Yesterday, I received some distressing news: our EMS crews were called to a cardiac arrest, no breathing, possible overdose, to the same address a third time. Police were also dispatched, as usual, and they pushed nasal naloxone into the patient and then started CPR. This time, however, the patient did not make it to the hospital. A 53-year-old man, who had been saved twice before with naloxone and CPR, is no more. All too often we receive 911 calls for overdoses, seizures in known drug users, snoring respirations, and cold bodies with needles in their arms. What was once considered a big-city problem has infected small-town America, and no one knows of any cures for opioid addiction.

The Centers for Medicare & Medicaid Services (CMS) developed a comprehensive morphine equivalent dose (MED) approach to assist Part D sponsors in identifying “potential opioid overutilizers” as those whose daily MED exceeds 120 mg for at least 90 consecutive days, with more than 3 prescribers and more than 3 pharmacies contributing to their opioid claims during the most recent 12 months (excluding beneficiaries with cancer diagnoses and beneficiaries in hospice).

A CMS analysis of Part D claims’ data via what it calls the Overutilization Monitoring System (OMS) in 2013 identified 25,347 potential opioid overutilizers.

CMS subsequently recommended revising the criteria to identify high-risk beneficiaries to align with recently published guidelines from the Centers for Disease Control and Prevention (CDC): using 6 months as the time frame for opioid users with an average daily MED equal to or exceeding 90 mg for any duration, and received opioids from more than 3 prescribers and more than 3 pharmacies, OR from more than 4 prescribers regardless of the number of dispensing pharmacies. The revised criteria increased the number of beneficiaries being potential overutilizers to 33,223.

While the initial program did decrease the number of beneficiaries who met the criteria over the next 3 years, and also changed prescribing patterns and behavior, did it decrease the number of opioid addicts?

The CDC states that, every day, we lose 91 Americans to opioid overdoses, and the number of prescription opioid-related deaths has quadrupled since 1999—so the problem is still growing. Once a patient, even for legitimate pain-related purposes, obtains opioids from 4 separate prescribers or 3 prescribers at 3 separate pharmacies within a 6-month period, they likely have a real prescription opioid addiction problem. At that point, the patient can either address the addiction problem or seek other illegitimate sources for opioids—the latter of which happens far more often.

So the question remains, how can CMS and Part D plans mitigate inappropriate opioid prescriptions while still providing access to pain management for legitimate purposes? I don’t know the answer, but we need to do far more, in my opinion, because the epidemic is everywhere, including in small-town America; at least three-quarters of the people in my town with whom I’ll speak, bump into at the post office, or smile at while in the grocery store check-out line, knew that 53-year-old man who died yesterday and his wife and their children.


Patient Assistance and Access Programs (PAP) Conference


March 16–17 | Baltimore, MD

We are living in a time of incredible transformation for the healthcare industry, and it’s becoming increasingly important for us to learn from each other and stay informed on the critical issues that impact us, patients, and providers. One of the best venues for new insight on how to improve patient access is CBI’s annual PAP conference, where you can hear from top minds in the industry on the latest developments and innovations that help to ensure access to treatment for patients.
Lash Group’s Tracy Foster will again deliver the keynote address at this conference, leading a lively and informative session titled, “Serving Patients Through the Power of Partnership.” Join Tracy as she examines those key relationships within the system that allow us to meet the variety of needs across the healthcare continuum and provide the best support for patients. Learn more




Senator Vows to Review Rules to Counteract Price Hikes


Republican Sen. Tom Cotton (R-AR), reacting to the approval and subsequent pricing of Marathon Pharmaceutical’s EMFLAZA™ (deflazacort), pledged to ask Congress to review federal rules on drug importation and orphan drugs to combat high drug prices.

“We have a drug here that used to be available for $1,500 a year and now it is $89,000 a year. Whatever happened, that is a system-wide failure, and we as a Congress have to address it,” Cotton said, reacting to news reports about deflazacort, a steroid that until recently was not approved in the US but was being imported from other countries as a treatment for Duchenne muscular dystrophy at a cost of about $1,500 a year. Because it is now approved by the Food and Drug Administration (FDA), importation from abroad is no longer allowed.

The FDA’s February 9, 2017 approval for EMFLAZA granted Marathon 7 years of marketing exclusivity. Marathon said the pricing reflects its investment to commercialize the drug, including resources needed to complete phase 4 clinical studies and FDA post-marketing study commitments. The company added that FDA approval means there is now information on proper dosing, potential side effects, and drug-to-drug interactions for the drug in Duchenne patients. Marathon, which “paused” the drug’s launch last week to meet with Duchenne patient advocates and lawmakers, said it plans to continue research and development on new treatments for the disease and also expand access through a drug assistance program for those who do not have insurance coverage or adequate financial resources to afford the treatment.

Cotton’s comments come at a time when it seems, every week, a different Republican or Democratic lawmaker calls for expanding regulatory authority to counteract drug price increases. What is newly noteworthy, of course, is Republicans are now joining the discussion; that party has traditionally stayed away from calls to expand regulatory influence to curb unpopular drug prices. Now that Republicans control the House and Senate, as well as the Executive Branch, their voices carry more weight.


Deadlines Extended for 2018 Exchange Participation


Late last week, the Department of Health and Human Services (HHS) released a revised timeline to allow insurers participating in the federally facilitated Marketplace more time for qualified health plan (QHP) certification and rate filing. The extended deadlines are part of a proposed rule published last week by CMS to increase the overall stability of the individual and small-group markets and potentially allow time for Congress to make changes that would impact 2018 before plan applications are due.

The table below compares the revised timeline to the original list of key 2017 dates.

The updated timeline also removes 4 previous milestones, including CMS sending an initial plan confirmation list and deadlines for issuers to submit revised data and a second correction notice. Additionally, HHS proposed new timelines for the rate review of single risk pools. Besides removing 2 of the original 9 milestones (the target dates for CMS to post final rate changes and for states with an Effective Rate Review Program to post final rate increases), CMS moved out the deadline for submitting initial rate filings (5/3/2017 to 6/1/2017) and moved up the deadline for all rate filing justifications (8/21/2017 to 8/16/2017).

The new deadlines are designed to provide health insurers with more time to plan for their participation in the Marketplace next year. Nevertheless, major insurers are pulling out from the Exchanges, leaving many counties with only 1 insurer offering plans in 2017. The situation could be even worse in 2018, especially with disruptions caused by the tumultuous state of affairs over the Republicans’ attempt to reshape the healthcare system. While a worsening Marketplace feeds the Republican narrative that the Exchanges are imploding, it may also leave many people without access to health insurance, something neither party wants—particularly the Republicans in a mid-term election year.

Check out last week’s Health Policy Weekly to read more about the additional provisions proposed in the market stabilization rule.


Turns Out They Like it, They Really Like It: States and Medicaid Expansion


As the Trump Administration moves forward to repeal the ACA, discussion continues as to the potential consequences, particularly to state budgets and to the millions of people who have gained health insurance coverage with the ACA through Medicaid eligibility expansion. The Commonwealth Fund recently published an article discussing this topic.

Looking at the possibility of Congress eliminating or reducing coverage as part of the ACA repeal, the 31 states that expanded Medicaid coverage will be faced with the prospect of either maintaining coverage out of their own funds or dropping the estimated 11 million newly eligible beneficiaries of the program. No state will be in a position to support this population without considerable federal assistance; however, federal Medicaid rules require states to determine if there is another basis of eligibility before terminating coverage.

If the repeal bill instead retains the Medicaid expansion but reduces federal funding to traditional Medicaid levels, some states might seek flexibility to roll back coverage to a lower level, such as 75% of poverty, rather than the eligibility standard used under the expansion (138% of poverty).

If, in fact, Congress ends funding for Medicaid expansion, states can be expected to immediately begin to file repeal plans with the federal government, either by rolling back coverage added as a state option or by ending expansion.

Implementing a repeal of this magnitude will be a complex and expensive job for states to administer. According to CMS, Medicaid enrollment grew by 16.4 million between the first 2013 ACA open enrollment period and November 2016, the most recent Medicaid reporting period. Reversing Medicaid expansion without a concomitant approach to obtaining coverage for that population could negatively affect the biopharmaceutical industry along a number of avenues, including fewer patients filling prescriptions and more patients needing patient assistance programs and free drug benefits.


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:

  • It’s That Time of Year Again: The National Committee for Quality Assurance (NCQA) invites the public to comment on 2018 Healthcare Effectiveness Data and Information Set (HEDIS®) measures.
  • PDUFA, Where Have You Been? The House Energy and Commerce Health Subcommittee will hold its first hearing on reauthorization of the FDA user fee programs next week.
  • School of QPP: CMS awarded approximately $20 million to 11 organizations for the first year of a 5-year program to provide on-the-ground training and education about the Quality Payment Program (QPP) for clinicians in individual or small group practices of 15 clinicians or fewer.
  • Check Please: Gilead Sciences has agreed to buy a priority review voucher from Sarepta Therapeutics for $125 million.
  • Think Local: Mayors across the country held a National Mayors’ Day of Action on Wednesday to “stress the serious impact losing healthcare coverage would have.”

Adapting to ACA Uncertainty: The Future of Patient Support Programs


March 16–17 | Baltimore, MD

Join Xcenda’s Corey Ford, MHA, and Jennifer Johnson, MS, both Associate Directors of Reimbursement & Policy Insights, as they present a timely and very relevant session at the upcoming CBI Patient Assistance and Access Programs (PAP) Conference in Baltimore, MD.

Mr. Ford and Ms. Johnson will discuss the future of the ACA and its likely repeal or replacement by the current Administration. They will also provide insight on the impact to both patient access and patient support programs, as well as identify areas of consideration to facilitate patient access in this time of change.




“[Republican lawmakers will] fix Obamacare, and I shouldn’t have called it repeal and replace because that’s not what’s going to happen. They’re basically going to fix the flaws and put a more conservative box around it.”

– John Boehner, former House Speaker, speaking at the 2017 Healthcare Information and Management Systems Society (HIMSS) Annual Conference & Exhibition

Source: “Boehner: Republicans won’t repeal and replace Obamacare,” Politico, February 23

43% | 67%


In a study of 38,096 people undergoing treatment for opioid use disorder by taking buprenorphine, 43% filled an opioid prescription during the treatment episode, and 67% filled an opioid prescription following treatment, showing how unsuccessful the opioid addiction treatment drug buprenorphine is at weaning patients completely off opioids.

Source: “Non-buprenorphine opioid utilization among patients using buprenorphine,” Addiction, February 23


CBI 18th Annual Patient Assistance & Access Programs

March 16–17 l Baltimore, MD
Join AmerisourceBergen companies, Lash Group and Xcenda, at the premier conference for patient assistance and access programs. Tracy Foster, President of Lash Group, presents the keynote address titled, “Serving Patients Through the Power of Partnership.” Xcenda's Corey Ford and Jennifer Johnson, both Associate Directors of Reimbursement & Policy Insights, will present a session titled, "Adapting to ACA Uncertainty: The Future of Patient Support Programs." Learn more


AMCP Webinar: Driving Value and Outcomes in Oncology

March 22 l Webinar
Kellie Meyer, PharmD, MPH, Senior Director of Global Health Economics, joins a panel of experts for a live webinar discussing the proceedings of a recent AMCP Partnership Forum titled, “Driving Value and Outcomes in Oncology.” Forum stakeholders will share the ideas and concepts discussed at the forum to help sort through a wave of new oncology products coming to market each year. Register now


AMCP 2017 Annual Meeting & Expo

March 27–30 l Denver, CO
Join leaders from AmerisourceBergen, US Bioservices, and Xcenda for the 29th Annual AMCP Meeting & Expo at booth #513. Learn more about the integrated solutions and insights that will drive success across healthcare delivery. Learn more


Asembia Specialty Pharmacy Summit 2017

April 30–May 3 l Las Vegas, NV
Join Xcenda at the largest US conference for specialty pharmacy. Matt Sarnes, PharmD, Senior Vice President of Commercial Consulting at Xcenda, will present, “The Future of FDAMA 114—How Will It Impact Access to Specialty Therapies?” 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

Loreen Brown, LMSW
Senior Vice President | Product, Strategy & Commercialization Excellence | Lash 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


Jennifer Le | Katherine Bridges Maness | Scott Shields Aileen Soper | Diane Wilson | Stephen Wilson 


Laurie Kozbelt | Ellen Olson | Jeff Bunting


Feb. 24, 2017


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