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I guess this is the week where we’re going to talk about smoothing**.
I mentioned on Tuesday that there hasn’t been much in the way of explanatory work about the Medicare Prescription Payment Plan/MPPP/M3P, only to find out that CMS had just dropped an explanatory video and webpage.
And, at first blush, the CMS page was pretty good. The accompanying video was concise and clear and didn’t necessarily shy away from some of the complexities of MPPP.
But then I started to play with the “will this payment option help me” tool on the website that is designed to help seniors determine if the MPPP might help them.
And that tool has a lot of problems:
If you mention that you’re on a patient assistance program from a manufacturer, CMS will suggest that MPPP might not be right for you. That’s downright bad advice, because it sounds like some patient assistance programs may mandate MPPP participation. CMS needs to tighten up there.
If you suggest that your drug costs are less than $2,000 a year, CMS will tell you that MPPP probably won’t work. That’s less-than-ideal for a couple of reasons. First — as well documented by Milliman — some patients will hit the out-of-pocket cap with less than $2,000 in spending, so it’s possible to fully smooth even with less than $2,000 in spending. Second, MPPP does gets more complicated for those with less than $2,000 in drug costs — with monthly payments bouncing around and rising toward the end of the year — but it’s possible that the cadence of payments is better than the current get-soaked-in-January/February plan.
If you tell the tool that your payments are consistent and affordable, it’ll recommend against the MPPP, which seems pretty prescriptive. Personally, I have drug costs that are consistent, and I can “afford” them, but I would still rather not have to deal with deductibles straight off the hop in January. Steering people away from the option doesn’t feel quite right.
At the 30,000-foot level, the advice probably isn’t terrible (except for the first bullet, which has the potential to be terrible). Yes, MPPP is going to give ice-cream headaches to anyone who isn’t hitting the $2,000 cap, but that doesn’t mean some of those patients wouldn’t benefit.
All of this underscores the point of my newsletter on Tuesday: this is complicated stuff, we’re already in, like, the 8th inning, and Medicare beneficiaries are not remotely prepared for their at-bat next month when open enrollment kicks off.
I predicted yesterday that this was “a goat rodeo in the making,” and — having played with the CMS tool — all I can say is: giddyup.
** Actually, “smoothing,” as a term, is going out of style. The theory is that no one quite wants to call it “smoothing” because it implies that drug costs will be smooth, month-to-month, and that’s not how it will go down for a lot of patients. So while I’m not going to completely abandon “smoothing,” I’ll be using it a lot less.
But there’s still a question of what term we should be using. So I’ll let you all vote:
Most of today’s Quick Turns are mini-rants because, apparently, I’m irritable this morning.
There was a good, smart, PBM hearing on Capitol Hill yesterday, with lots of thoughtful exposition of the current environment, and — to the best of Google’s knowledge — no one wrote about it, and no member of Congress even bothered writing a statement about it. Here are the witness statements anyway. And you should still read the USC JAMA research about consolidation.
This is a terrible Quartz piece complaining about the lack of drug-pricing mentions in the debate and then claiming that drug prices are rising at 15% a year, which isn’t remotely true, regardless of what standard you use. It’s hard to have thoughtful debates when numbers aren’t being used thoughtfully, but here we are.
Biospace has an overview of the PBM debates that is, eh, fine. But it rolls out a weird “to be sure” line, arguing that PBM reform might not be a huge deal because “retail prescription drugs, which PBMs oversee, account for a mere 9% of healthcare spending in the country.”
Not everything is chapping my hide. This Raleigh News & Observer piece on the death of independent pharmacies — the no. 1 health care story in America — is a solid and welcome piece of journalism.
And the N&O also had a nice — if brief — writeup on the PBM that UNC Health built, noting the model: “While other PBMs focus on negotiating rebates from drug manufacturers in exchange for including a drug or drugs on the PBM’s formulary, UNC Health’s Managed Pharmacy Solutions focuses on obtaining drugs for the lowest price and passing those savings along.”
In other non-irritating news: This Bloomberg interview with J&J execs includes some of the established IRA messaging, highlighting that the law will have bad long-term effects, even if the short-term impacts can be managed. And you should probably read the KFF polling on how voters are thinking about health care, if only because it underscores how politically marginal the topic of drug pricing is. More thoughts on that to come.
I don’t quite know what to make of this CVS letter pushing back on Rep. James Comer’s allegations that PBM execs lied before his committee. The CVS response doubles down on the idea that the company does not steer business to its pharmacies, and it takes some shots at the FTC while it’s at it. Regardless of where you stand on things, this is a must-read if you’re into the PBM conversation.
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