U.S. Department of Health & Human Services, Office of Inspector General, June 2018

What OIG Found

* Total reimbursement for all brand-name drugs in Part D increased 77 percent from 2011 to 2015, despite a 17-percent decrease in the number of prescriptions for these drugs.

* After accounting for manufacturer rebates, reimbursement for brand-name drugs in Part D still increased 62 percent from 2011 to 2015.

* Part D unit costs for brand-name drugs rose nearly 6 times faster than inflation from 2011 to 2015.

* The percentage of beneficiaries responsible for out-of-pocket costs of at least $2,000 per year for brand-name drugs nearly doubled across the 5-year span.

Conclusion

We found that, over a 5-year period, increases in Part D reimbursement for brand-name drugs outpaced inflation. Despite a decrease in utilization of brand-name drugs, these substantial increases in reimbursement led to greater Medicare spending and higher beneficiary out-of-pocket costs for these drugs. Specifically, total Part D reimbursement for all brand-name drugs increased 77 percent, from $58 billion in 2011 to $102 billion in 2015. To control for the possibilities that (1) increases in utilization or (2) newer, more expensive brand-name drugs may have affected total Part D reimbursement, we analyzed the number of prescriptions and unit costs for brand-name drugs that were reimbursed in every year from 2011 to 2015. Overall, we found that utilization decreased for the majority of these brand-name drugs, while the average Part D unit cost increased 29 percent from 2011 to 2015.

Increases in Part D unit costs significantly outpaced inflation; in fact, the average unit cost for brand-name drugs in Part D rose nearly 6 times faster than inflation from 2011 to 2015. We also found that Part D unit costs closely followed the upward trend in benchmark prices, which are typically reflective of manufacturer prices. Therefore—like the 2016 ASPE report, which suggested that increases in drug prices contributed to the growth in total prescription drug spending—we conclude that increases in unit prices for brand-name drugs resulted in Medicare and its beneficiaries’ paying more for these drugs.

We also found that the percentage of beneficiaries who were responsible for out-of-pocket costs of at least $2,000 per year for brand-name drugs nearly doubled across the 5 years. These trends are consistent with those described in the previous OIG report, which found increases in the number of beneficiaries who reached the catastrophic-coverage phase of their Part D benefits. In addition, we found that total beneficiary out-of-pocket costs were highest for brand-name drugs in three therapeutic classes of maintenance drugs (insulins, cholesterol reducers, and respiratory tract corticosteroids). Because maintenance drugs are typically used to treat chronic, long-term conditions, increasing reimbursement for these drugs will continue to affect Part D and its beneficiaries for years to come. OIG remains committed to examining these issues and working with CMS to ensure the integrity of the Part D program.

https://oig.hhs.gov…

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Comment:

By Don McCanne, M.D.

Probably the most significant finding in this OIG study is that the unit costs (prices paid) for brand-name drugs in Medicare Part D rose six times faster than the rate of inflation. Although the use of brand-name drugs has declined 17 percent, the total reimbursement has increased 77 percent because of these unit cost increases.

These escalating unit costs are borne by both the taxpayers who fund Medicare and the patients who are paying higher out-of-pocket costs. The spending increases have been particularly burdensome for patients requiring maintenance drugs for chronic conditions.

We do not have to continue to put up with this. Last month, a group associated with Physicians for a National Health Program released a proposal that would ensure universal access to safer, more innovative, and more affordable drugs. The report can be accessed at the following link:

https://pnhp.org/pharma

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By Deborah Peikes, Stacy Dale, et al (Mathematica Policy Research and Center for Medicare and Medicaid Innovation)
Health Affairs, May 23, 2018

Abstract

The Comprehensive Primary Care Initiative (CPC), a health care delivery model developed by the Centers for Medicare and Medicaid Services (CMS), tested whether multipayer support of 502 primary care practices across the country would improve primary care delivery, improve care quality, or reduce spending. We evaluated the initiative’s effects on care delivery and outcomes for fee-for-service Medicare beneficiaries attributed to initiative practices, relative to those attributed to matched comparison practices. CPC practices reported improvements in primary care delivery, including care management for high-risk patients, enhanced access, and improved coordination of care transitions. The initiative slowed growth in emergency department visits by 2 percent in CPC practices, relative to comparison practices. However, it did not reduce Medicare spending enough to cover care management fees or appreciably improve physician or beneficiary experience or practice performance on a limited set of Medicare claims-based quality measures. As CMS and other payers increasingly use alternative payment models that reward quality and value, CPC provides important lessons about supporting practices in transforming care.

From the Introduction

Public and private payers are increasingly experimenting with ways to improve primary care delivery, reduce spending, and improve patient outcomes. Payers are also considering ways to strengthen primary care. New primary care models, such as the patient-centered medical home, have had mixed effects on quality and spending.

The Centers for Medicare and Medicaid Services (CMS) launched the Comprehensive Primary Care Initiative (CPC) in October 2012. CPC tested whether requiring practices to implement a new approach to delivering primary care, and providing financial and technical support to help them do so, reduced spending and improved quality over a four-year period in 502 practices across seven US regions. In addition to CMS, thirty-nine other private and public payers supported CPC practices by implementing an aligned approach to changing care delivery and payment.

This article provides an update to earlier evaluation results of the first two years of CPC.

EFFECTS ON SPENDING AND SERVICE USE

Our estimates showed no significant differences in spending growth during CPC, with or without care management fees.

EFFECTS ON QUALITY OF CARE AND PATIENT EXPERIENCE

Over the course of CPC, we found no significant effects on the claims-based quality-of-care process measures for beneficiaries with diabetes or on the continuity-of-care measure, defined as the percentage of primary care visits that occurred at the practice that the beneficiary was attributed to when CPC began.

EFFECTS ON PHYSICIAN EXPERIENCE

Physicians in CPC practices had largely favorable views of CPC in 2016. However, many indicated that CPC’s administrative reporting was a burden and the transformation work was difficult.

Although CPC required intensive work for practices, we found no meaningful differences on measures of burnout, control over work, alignment of work with training, and job satisfaction between physicians in CPC practices and those in comparison practices in 2013 or 2016.

From the Discussion

Practices participating in the Comprehensive Primary Care Initiative improved some aspects of care delivery, which in turn led to less growth (relative to comparison practices) in numbers of ED visits and thirty-day ED revisits among fee-for-service Medicare attributed patients. However, the four-year initiative did not reduce Medicare hospitalizations or reduce Parts A and B spending enough to cover care management fees. There were no appreciable improvements in patient experience, claims-based quality of care, or physician experience, except that patients reported more follow-up care after hospitalizations and ED visits. Beyond the reduction in ED visits, the additional two years to transform care delivery did not substantively alter the earlier results from midway through the initiative.

Results from CPC illustrate how hard it is to reduce Medicare spending. There are several potential reasons why the findings were not more favorable. First, primary care practices might need stronger value-based financial incentives, accompanied by strong and consistent incentives for other providers (such as specialists and hospitals) that care for the same patients.

Second, some participating practices reported facing barriers to improving care delivery (for example, the burden of reporting, potentially limited actionability of data feedback, insufficient health information technology support for care delivery, and poor health information exchange) that may have made implementation of the initiative less robust than it might have been without such barriers.

Third, general care delivery improvements by comparison practices and other providers—for example, in response to Medicare’s financial penalties for high readmission rates—could have made it challenging for CPC practices to improve their outcomes relative to those of comparison practices.

CPC+

CPC+ aims to improve on these outcomes by building several new elements on the same foundation of multipayer support and five primary care functions. First, CPC+ introduces a second track that deepens care delivery requirements for practices with more experience in delivering advanced primary care.

Second, CPC+ further moves away from traditional fee-for-service by providing a hybrid payment for practices in the second track (combining a portion of fee-for-service and global payment for evaluation and management services).

Third, CPC+ strengthens incentives. It replaces shared savings with a prepaid bonus that practices must repay if they do not meet practice-level performance targets.

Finally, CMS partners with health information technology vendors to encourage improvement in health information technology functionalities to support practices in meeting the care delivery requirements of CPC+.

https://www.healthaffairs.org…

Full report from Mathematica Policy Research (over 300 pages):
https://downloads.cms.gov…

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Comment:

By Don McCanne, M.D.

CMS is fixated on pushing the health care delivery system into accountable alternative payment models. The Comprehensive Primary Care Initiative is a study that has been going on for four years, and yet the improvements are negligible.

Instead of moving forward with a financing system that really would improve health care spending, CMS is going to expand this experiment with measures such as replacing shared savings with “a prepaid bonus that practices must repay if they do not meet practice-level performance targets.” That’s bizarre since we already know that such policies reduce physician satisfaction and increase burnout. That can’t be their policy goal, or is it?

Enough experimentation with alternative payment models. We definitely need to keep improving primary care, but not with financing policies that don’t work. Let’s go right to the model that does work – a well designed, single payer, improved Medicare for all. Within that system we can refine primary care to make it work well for all of us – patients and health care professionals alike.

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By Clara Son
Avalere, May 22, 2018

New research from Avalere finds that seniors with Medicare prescription drug plans (Part D) pay more for generic drugs even as the market price of these drugs stays stable.

Avalere experts note that seniors are paying more because generic drugs are being placed on higher formulary tiers where patients pay more out of pocket for drugs. The number of generic prescription drugs placed on the lowest tier, where patients pay less for their drugs, declined 53 percentage points between 2011 and 2015. This shift resulted in a 93% increase in total patient cost sharing for these drugs, or a total of $6.2 billion.

This higher cost sharing and movement of generics to higher tiers did not correspond with an increase in the underlying price of generic drugs over that same time period, according to an analysis by Avalere experts of the average volume-weighted price of generics that were included on plan formularies in both 2011 and 2015.

In 2011, 71% of generic drugs were placed on tier 1, the lowest tier in the formulary. By 2015, 19% of covered generics were placed on tier 1, while 46% were placed on tier 2 and 35% were placed on tier 3 or higher. This shift represents a 53 percentage point decrease in the number of generics being placed on the lowest tier between 2011 and 2015.

The use of generic drugs has saved the Medicare Part D program billions of dollars. However, higher tier placement of generic drugs is leading to higher out-of-pocket costs for patients and may reduce savings.

http://avalere.com…

In response, the Pharmaceutical Care Management Association (PCMA) released the following statement which still does not refute the fact that the industry moved more expensive generics into non preferred tiers in order to keep Part D premiums competitive:

https://www.prnewswire.com…

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Comment:

By Don McCanne, M.D.

This report confirms that the industry shifted over half of generic drugs out of the lowest tier into higher tiers wherein patient cost sharing is higher. This benefits the pharmacy benefit managers because the shift in costs to the patients allows them to keep the Part D premiums more competitive, but it certainly has an adverse impact on seniors who are dependent on generic medications that are supposed to be cheaper than the brand names.

In fact, it has been reported that the cost sharing of generic drugs is sometimes greater than the full price of the generic if it were purchased without using the insurance, and the pharmacy benefit managers may have gag clauses prohibiting the pharmacist from telling the patient that it would cost less if they didn’t use their insurance. Would you call this nefarious?

This is one more example of how the private sector takes good care of the industry itself while using the patients as pawns. Not only are prices high, insurance premiums are unaffordable for many, and they also shift more costs to patients’ pockets as they take away their choices in health care, whether through narrow provider networks or through unaffordable deductibles and other cost sharing. To add to the insult, we pay more because of the high costs of administering these shenanigans.

Through a well designed, single payer, improved Medicare for all we would have the full range of choices in health care with no need for the patient to share costs of the health care services and products at the point of service. When people need care, they simply get the care they need. And, of course, everyone is included for life, and we can do that without spending any more than we already do by using equitable public financing.

Now explain again the basis of those disingenuous arguments that are going around that this approach is not feasible. It is the only approach that is feasible if we want everyone to have affordable health care.

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