One of the few things the House of Representatives managed to accomplish in 2023 was the passage on December 11 of H.R. 5378, the Lower Costs, More Transparency Act, a bipartisan healthcare bill that would impose new transparency requirements on Pharmacy Benefit Managers (PBMs).
If passed into law, the measure would increase reporting requirements for insurers, hospitals, and pharmacy benefit managers, which manage prescription drugs for insurers.
Starting in 2025 Medicare Advantage organizations would have to report information to HHS on incentive-based payments made to healthcare providers with a financial ownership interest in the Medicare Advantage company.
Medicare Part D drug plan sponsors would have to report to HHS on each pharmacy in which the sponsor, or a pharmacy benefit manager offering services under the plan, has an ownership or control interest.
Starting in 2029, the Medicare Payment Advisory Commission would have to release a report on the state of vertical integration in Medicare every three years.
In addition, Medicare and its beneficiaries would pay the same rate for physician-administered drugs in hospital outpatient departments outside the hospital facility as they do in physician offices, which typically have lower payment rates.
HHS would phase in the provision over four years, with the site-neutral payments being fully applicable beginning in 2028 or 2029 for hospitals in rural areas or areas with a shortage of healthcare workers.
Unsurprisingly, hospitals and PBMs have pushed back against the legislation.
