Proposed Rule Aimed at Lowering Medicare Advantage and Part D Drug Prices by AzHHA

Debbie Johnston, Senior Vice President of Policy Development

On November 26th the Centers for Medicare & Medicaid Services (CMS) released a proposed rule aimed at lowering drug prices for beneficiaries enrolled in Medicare Advantage (MA) and Part D programs. The proposed rule seeks to ensure that MA and Part D plans have more tools to negotiate lower drug prices for seniors enrolled in Medicare. In addition, this proposal indicates that the agency is considering a policy that would require pharmacy rebates to be passed on to seniors to lower their drug costs at the pharmacy.

The proposed rule would:

  • Provide Part D plans with the option to exclude certain drugs from current “protected” therapeutic classes, allowing plans to negotiate the price of excluded drugs, potentially translating to lower costs for seniors at the counter.

  • Require Part D plans to increase transparency and provide enrollees and their doctors with a patient’s out-of-pocket cost obligations for prescription drugs when a prescription is written.

  • Prohibit pharmacy gag clauses in Part D prescription drug plans.

  • Similar to a 2019 MA Part B step therapy policy, codify regulatory language that allows MA plans to require step therapy in an attempt to increase access to high-value products, including biosimilars.

Consider a policy for a future plan year, potentially as early as 2020, that would ensure enrollees pay the lowest cost for the prescription drugs they pick up at the pharmacy.

The Administration’s continued focus on lowering prescription drug costs is appreciated considering the threat that high and rising drug costs pose to patient access to care, especially for seniors. However, we have concerns about provisions in the proposed rule that may negatively impact patient access to care. CMS will accept comments on the rule through January 25th.

Latest DataGen Reports and Resources by AzHHA

Ann-Marie Alameddin, Vice President of Strategy and General Counsel

DataGen reports are sent to hospitals as a part of AzHHA membership. DataGen utilizes Medicare analytics to create hospital-specific reports that support hospital operations, finance and enhance quality initiatives.

The following DataGen reports were sent by AzHHA Analytics to our members:

·         FFY 2020 Readmissions Reduction Program Analysis                           Sent 10/15/18

·         3Q2018 Quality Program Measure Trends Analysis                               Sent 11/14/18

·         CY 2019 Medicare Outpatient Prospective Payment System final rule  Sent 11/28/18

Need more details about the CY 2019 Medicare Outpatient Prospective Payment System final rule? AzHHA is offering a final rule analysis to members on December 10th. Please contact AzHHA Analytics if you have questions on how to register for the webinar.  

If you would like a copy of your hospital report emailed to you, please email AzHHA Analytics. For more information on the 2018 DataGen schedule for release of DataGen reports, click here.

Last Call: Ad Placement in the 2019 Arizona Hospital Directory by AzHHA

Shayna Diamond, Director of Community Affairs

The deadline to submit ads to E&M Consulting, Inc. for the 2019 Arizona Hospital Directory is Friday, December 7th. . If you would like to have your organization or company featured in this publication, please contact Rob with E&M Consulting at 602-412-3521 or Information on the available advertising opportunities can be viewed online at  

The Biggest Untapped Lever in ACO and Bundled Payment Success by AzHHA

John Koeneke, Vice President of Business Development

Learn how to secure the physician and payer partnership needed for optimal performance by joining AzHHA APP member, Sound Physicians and Blue Cross Blue Shield of North Carolina in the ACO and Bundled payment Success webinar on December 7th.  Presenters will have an in-depth discussion on the lessons learned from the last five years of CMS’ alternative payment model test, scale and adoption. Attendees will learn about:

  • Physicians – the biggest untapped opportunity in managing acute care episode outcomes

  • What doesn’t work – how to avoid the common stumbling blocks to successful implementation of care delivery redesign

  • The future of alternative payment models for public and private payers

For more information about the webinar and to register, click here.

Point of Pride: Maricopa Integrated Health System by AzHHA

Changes will be taking place next year for AzHHA member Maricopa Integrated Health System (MIHS). MIHS will be changing its name to Valleywise Health mid-2019. The name change is part of the transformation of the healthcare system occurring thanks to overwhelming approval of Proposition 480 by Maricopa County voters in 2014. This brand change will allow consumers to more easily identify Valleywise Health care locations and services.