Bills Would Require Prompt Payment Of Pharmacists' Medicare Rx Benefit Claims

Main Category: Medicare / Medicaid / SCHIP
Article Date: 12 Apr 2006 - 2:00 PDT

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Senate Republicans and Democrats have introduced separate bills that would require Medicare prescription drug plans to reimburse pharmacists' claims within specified timeframes, CQ HealthBeat reports. One bill (S 2563) -- by Republican Sens. Thad Cochran (R-Miss.), Michael Enzi (R-Wyo.) and Jim Talent (R-Mo.) -- would require pharmacists to be reimbursed within 14 days of filing electronic claims and within 30 days of filing paper claims. Under the second bill (S 2551), by Democrats Sens. Robert Menendez (D-N.J.) and Frank Lautenberg (D-N.J.), all prescription drug plan providers would be required to reimburse pharmacists, physicians and hospitals within 14 days of an electronic claim being filed and within 30 days of a paper claim being filed. The bills follow complaints from many pharmacists that they are losing money under the Medicare drug benefit because of slow payments from pharmacy benefits managers and other payers. Some pharmacists allege that pharmacy benefit managers are intentionally delaying payments or offering low reimbursements to increase profits, CQ HealthBeat reports.

Comments
Menendez said, "A federal prompt pay law is critical to ensuring that our pharmacies and health care providers maintain adequate cash flows to continue functioning." Mike James, vice president of the Association of Community Pharmacists Congressional Network, said the Republican bill addresses "the urgent need to protect the world's best drug delivery system by ensuring PBMs reimburse pharmacies in a timely manner." However, Phil Blando, a spokesperson for the Pharmaceutical Care Management Association, said the legislation is "premature," adding, "We're troubled that less than 100 days into this program policymakers are already trying to open it up and rewrite the rules that govern the program." Blando said PBMs currently are paying routine claims within 15 to 30 days. HHS Secretary Mike Leavitt said his agency has sufficient authority to address the reimbursement delays without legislation. Leavitt said HHS will take steps to ensure that plans pay reimbursements within the timeframes specified in their contracts. "[T]he plans need to meet their contracts," he said (Carey, CQ HealthBeat, 4/7).

Copayments
In related news, the New York Times on Saturday published two articles examining how the drug benefit is affecting access to medications for cancer patients. Summaries appear below.

• "Drug Plans' Side Effect Is Severe": The article examines how some beneficiaries have been unable to obtain certain cancer medications under the drug benefit because they cannot afford to pay for the treatments in the so-called "doughnut hole" coverage gap. Under the doughnut hole provision of the 2003 Medicare law, beneficiaries are responsible for all annual drug costs between $2,250 and $5,100. Before the drug benefit began, many beneficiaries without prescription drug coverage were able to obtain the medications at no cost from the drugs' manufacturers or through other assistance programs. However, some pharmaceutical companies ended assistance programs for beneficiaries once the drug benefit began. Because of the high cost of the oral cancer treatments, beneficiaries taking the drugs reach the doughnut hole more quickly than others and "often must meet their entire annual co-payment requirement when they fill their first two prescriptions," the Times reports. The problem mostly affects beneficiaries prescribed medications that are taken orally in pill form and cost up to $4,000 monthly, including Gleevec, a stomach cancer treatment; Thalomid, a multiple myeloma treatment; and Tarceva, a lung cancer treatment (Berenson [1], New York Times, 4/8).
  


• "In Drug-Aid Foundations, a Web of Corporate Interests": The article examines the role of the pharmaceutical industry in funding foundations that help patients make copayments for high-cost prescription drugs. The foundations have been "busier than ever" since the Medicare drug benefit began as many beneficiaries face high copays under the doughnut hole provision, the Times reports. The article looks at the HealthWell Foundation, which was founded by for-profit health care consulting company Covance and receives most of its funding from pharmaceutical companies. According to the Times, critics of HealthWell and similar foundations claim "they are little more than ways for drug makers to sustain their high prices by funneling patients enough money to meet their copayments, while letting insurers pick up most of the bill." HealthWell President Stephen Weiner said the foundation is trying to diversify its funding sources to include donors other than pharmaceutical companies (Berenson [2], New York Times, 4/8).
  

'Success Stories'
AP/Long Island Newsday on Sunday examined how congressional supporters of the drug benefit are "stress[ing]" the benefits of the program amid concerns that "problems that marked its beginnings have drowned out success stories." According to Medicare Rx Education Network, about three-fourths of enrolled beneficiaries say they are satisfied with the drug benefit after they enroll. The article profiles beneficiaries who had difficulties with the enrollment process but now are saving money under the program (Freking, AP/Long Island Newsday, 4/9). Meanwhile, House Republicans have scheduled dozens of meetings and workshops during the two-week congressional recess to encourage their constituents to enroll in the drug benefit and counter "continuing attacks on the program from Democrats and others," the Washington Times reports. House Republicans have 200 events scheduled, and more are likely to be added, the Times reports (Fagan, Washington Times, 4/9).

Letter to the Editor
"A one-time delay" of the May deadline for enrolling in the drug benefit "is a sensible solution" for increasing enrollment, "given the confusion in this beginning period," Reps. Pete Stark (D-Calif.) and Jan Schakowsky (D-Ill.) and Sen. Bill Nelson (D-Fla.) write in a letter to the editor of the New York Times. Responding to a Times editorial published on April 3, the lawmakers say they "disagree" with assertions that "the 16 million elderly and people with disabilities on Medicare who haven't signed up for a Part D plan are 'dawdling' or that the deadline is a 'useful prod' to assure enrollment." In calling for the deadline to be extended until the end of the year, the lawmakers write, "We don't believe that America's elderly and people with disabilities should be forced to pay a lifetime of higher premiums or be rushed into making an uninformed choice" (Stark et al., New York Times, 4/9).

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