Senate and House committees turn attention to drug pricing and affordability.

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Sept. 27, 2019


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Impeachment: At Least it Made Less News out of Drug Pricing in Congress?


With much of the focus this week on other matters, discussions on drug pricing still occurred but with a little less fanfare.

On Wednesday, House Energy and Commerce Health Subcommittee held a hearing on “Making Prescription Drugs More Affordable: Legislation to Negotiate a Better Deal for Americans.” As might be expected, the hearing was particularly partisan, with Democrats praising the legislative efforts in question and Republicans saying that the bills would restrict access and represent price controls. One area of bipartisanship remains the out-of-pocket (OOP) cap for Medicare Part D.

There was a second House hearing on Thursday by the health panel of the House Education and Labor Committee. In this hearing, Democrats focused on the parallels between their proposals and those made by President Trump. Republicans countered with concerns over the impact of these changes on innovation. Next steps seem to be leaning toward getting a floor vote by the end of October.

On the Senate side, the Senate Finance Committee released text of its “Prescription Drug Pricing Reduction Act of 2019” (PDPRA), with a preliminary Congressional Budget Office (CBO) score of reductions to the deficit totaling more than $20 billion from 2020 to 2024 and $100 billion from 2020 to 2029. The text mirrors the Chairman’s mark-up from July and includes such changes as the OOP cap for Part D, inflationary penalties in Part B and Part D, and changes to biosimilar reimbursement to incentivize provider uptake. The timing here seems to be a little slower, with a full CBO score not expected for some time and a vote not likely to occur this year.

It’s uncertain whether the Senate and House can come together and agree on a package that could help patients—even with some of the similarities in the bills (the Part D OOP cap in H.R. 3 is $2,000, but other provisions are very similar, like inflation caps and pharmacy benefit manager [PBM] rebate disclosures). It is possible that something could be slipped into the “must do” appropriations bill due by November 21. In the meantime, it is clear that a lot of effort will be spent by the pharmaceutical industry battling these proposals while they become normalized in the minds of voters.


Pre-Approval Information: A 360-Degree View of Dossiers for Payers and Manufacturers


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Legislative Bytes

  • The Senate passed the “Fair and Accurate Medicaid Pricing Act,” or “Fair AMP Act,” (HR 3276), a bipartisan bill that would exclude certain authorized generic drugs from the calculation of average manufacturer price for brand drugs under the Medicaid Drug Rebate Program. The bill will make its way to President Trump’s desk along with the continuing resolution to fund the federal government until November 21.
  • The House Ways and Means Committee Democratic staff released a report comparing US prescription drug prices to international drug prices, noting that on average, Americans pay 4 times more—and in some cases up to 67 times more for the same drug.

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ICER and I Have Something in Common:
They Make Me Want to Evaluate Headache Treatments, Too


Earlier this month, ISPOR Latin America explored key issues around the future of data and value in healthcare, and several value-related presentations and sessions were featured. One presentation focused on the ethical dilemmas of value assessment frameworks (VAFs), citing issues such as varying perspectives (patient, society, provider, or payer), challenges associated with patients who have multiple chronic or complex conditions, and the difficulties of balancing health needs and costs.

An issue panel discussed the need for a VAF tailored specifically for diagnostic technologies and presented a pilot VAF to address this gap. Another poster presented preliminary results from a study that implemented a value-based care program in 40 hospitals in 5 different Latin American countries.

Additionally, the European Network for Health Technology Assessment released its draft methodological guideline on “Practical considerations when critically assessing economic evaluations.” The recommendations focus on the methodological challenges encountered while performing comparative effectiveness evaluations of drugs and other health technologies. The document is open for public comment until October 11.

Lastly, the Institute for Clinical and Economic Review (ICER) posted its model analysis plan for the evaluation of treatments for acute migraine. Manufacturers participating in the evaluation can provide written feedback to ICER through October 9.

As always, if you need assistance with all things ICER or value-related, please contact

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Taking Credit Where It's Not Due: Premiums Lower Because of Manufacturer-Provided Discounts and Rebates, Not Magical Policy Changes


On Tuesday, the Centers for Medicare & Medicaid Services (CMS) made its annual announcement on Medicare Advantage (MA) and Part D plan premiums in advance of the 2020 open enrollment season starting in October.

2020 MA plans

  • Decrease in average monthly premiums of 14% or $23 (estimated)—the lowest in the last 13 years
  • Expansion of options to enrollees with approximately 1,200 more MA plans operating in 2020 than in 2018, increasing the average number of MA plan choices per county from about 33 plans in 2019 to 39 plans in 2020—an increase of 49% since 2017

2020 Part D plans

  • Decrease in premiums from 2017, a 13.5% decline in the average monthly basic Part D premium to $30 in 2020—the lowest the Part D basic premium has been since 2013

Earlier this Fall, CMS also announced changes to the Medicare Plan Finder tool. CMS redesigned the Plan Finder tool to more easily compare Star Ratings and monthly premium pricing between MA and Part D plans, original Medicare and Medicare supplemental insurance, or Medigap policies. They also added information on drug pricing so beneficiaries can more easily see OOP costs and determine if there are lower-cost alternatives for the prescription drugs they take.

As news of these changes breaks just before Open Enrollment period (October 15–December 7, 2019), more Medicare beneficiaries are projected to enroll in MA plans. Out of approximately 60 million people currently enrolled in Medicare, CMS projects enrollment to increase to 24.4 million beneficiaries from the current enrollment of 22.2 million—an increase of 30.6% since 2017.

At a time when healthcare costs continue to rise, lower MA and Part D plan premiums and more transparent cost options for plans and drugs are long overdue for seniors.


Busting the $20k Mark: Employer-Based Health Insurance Premiums


This week, the Kaiser Family Foundation (KFF) released the 2019 Employer Health Benefits Survey. The report is the result of interviews with over 2,000 public and private firms and is, at least to this editor, the best work out there on the employer market and where it is trending.

The survey shows that annual premiums for employer health insurance are up 5% from last year, reaching $20,576 for a family of 4, and typical OOP expenses for employees are averaging $6,015.

Looking more specifically at drug coverage, most employers are still opting for coinsurance rather than copayment for specialty drugs (52% compared to 45%), with the average coinsurance at 24% and the average copayment at $109. Of those enrollees who have a coinsurance for specialty drugs, 70% have a maximum dollar limit on the amount they must pay, though the average ceiling amount was not provided.

Of the larger employers (over 1,000 employees), only 27% responded that they received “most” of the negotiated rebate from their PBM or the health plan, with the remainder of responses indicating they received “some” (32%), others received “very little” (18%), and some (23%) didn’t know.

With ongoing discussion about differing “Medicare for All” plans or creating some type of public program option, it does shine more light on how well employer-based coverage is doing at keeping healthcare costs low. Even though premium growth has remained fairly low, the rate of increase is still above inflation—and the prices that employer plans pay for care are increasing at a faster pace than Medicare or Medicaid.

Read the KFF press release for more or view the results of the survey published in Health Affairs.


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:


“And we are learning the lengths to which certain not-for-profit hospitals go to collect the full list price from uninsured patients. These hospitals are referring patients to debt collectors, garnishing wages, placing liens on property, and even suing patients into bankruptcy.

This is unacceptable. Hospitals must be paid for their work, but it’s actions like these that have led to calls for a complete Washington takeover of the entire healthcare system.

There’s an old saying: success has many fathers, but failure is an orphan. No one wants to admit it, but if we’re all honest, we can agree that blame can be shared across the healthcare system. So, before we can fix the system, we must face the situation with honesty and clarity.”


Source: Remarks by Administrator Seema Verma at the American Hospital Association Regional Policy Board Meeting, September 10.


19.9% vs 13.8%


Surveys conducted by the Commonwealth Fund found that 13.8% of adults ages 19 to 64 are uninsured, a decrease from 19.9% just prior to the Affordable Care Act’s expansions, but statistically the same as in 2018.

Percent of adults ages 19–64 who were uninsured

Source: Collins SR, Gunja MZ. What do Americans think about their health coverage ahead of the 2020 election? Findings from the Commonwealth Fund Health Insurance in America Survey, March-June 2019 (Commonwealth Fund, Sept. 2019).


AMCP Nexus 2019

October 29November 1 | National Harbor, MD
Xcenda and Dymaxium are proud to join managed care colleagues in National Harbor, MD for 4 days that spotlight the innovative practices currently impacting the managed care and healthcare community. Join us at booths #311 and #313. 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
Vice President,
Reimbursement and
Policy Insights,

Scott Shields
Associate Director,
Health Policy



Doug Cook
President | Commercialization Services & Animal Health

Kristine Flemister, PharmD
President | Xcenda

Tommy Bramley, PhD, RPh
President | Lash Group

Stacie Heller
Vice President | Government Policy | AmerisourceBergen Corporation

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

Ana Stojanovska
Vice President | Commercial Consulting | Xcenda


Anuja Kanaskar | Jenna Kappel | Joaquin Zabalza Seguin | Scott Shields


Kylie Matthews | Ellen Olson | Tia O'Brien


Sept. 27, 2019


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