Update for May 15, 2021

Update for May 15, 2021

Congress Considers Medicare Advantage Pre-Approval Legislation

According to a report from Modern Healthcare, Congress is considering changes to Medicare Advantage that would “crack down on prior authorization tactics insurers use to rein in healthcare costs but can affect how providers care for patients.”

A bi-partisan group of Representatives in the House has reintroduced a bill that aims to “quicken the prior authorization process and require more transparency about how often plans deny providers' requests.”

Prior authorization reform has long been a goal of provider groups like the American Medical Association, which says physicians are increasingly being told to get approval from insurance plans before a patient can access drugs, tests or treatments.

In a survey taken last year by the American Medical Association, 15% of physicians polled said prior authorization requirements always delayed access to necessary care for patients, while 39% said that often happened and 40% said it happened sometimes.

Prior authorization can also have an impact on physician practices, with 85% saying requirements pose a high or extremely high burden, and 40% saying they have staff who exclusively work on getting approval from insurance companies for treatment.

Insurers, on the other hand, argue that prior authorization helps reduce inappropriate care and thus reduces medical costs.

The purpose of the bill is said to be the creation of sensible rules that will result in giving transparency and oversight to the prior authorization process.

Under the bill, Medicare Advantage plans must establish electronic prior authorization programs and provide "real-time decisions" for some services that are routinely approved by insurers, to be determined by the Health and Human Services secretary.

The proposal would require Medicare Advantage plans with prior authorization requirements to submit an annual report to the HHS secretary listing which services require prior approval and how many requests were approved, denied and overturned after initial denials in the previous plan year. They would have to tell HHS the average and median amount of time between the submission of a prior authorization request and a determination from the plan.

Plans would also need to make the information available to providers they contract with and tell beneficiaries and providers the criteria for making prior authorization determinations. The bill encourages insurers to adopt prior authorization programs that adhere to evidence-based medical guidelines.

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Drug Price Legislation Facing a Surprise Problem

Last week Politico.com reported that major legislation meant to lower prescription drug prices has run into unexpected trouble in the House of Representatives.

It was always expected that few if any Republicans in the House of Representatives would support legislation to lower drug prices.  But it turns out that a group of moderate Democrats has now said they do not support the sweeping legislation that Democratic leaders in the House have proposed.

According to Politico, “At least 10 caucus moderates are signaling opposition to Democrats’ drug pricing negotiation bill — more than enough to potentially force House Speaker Nancy Pelosi into dropping the reforms from [President Biden’s] infrastructure legislation Democrats hope to pass along party lines. Pelosi can only spare two Democratic defections on partisan legislation because of the party’s slim House majority.”

The report also states that “House leaders have said they’re committed to moving forward on H.R. 3, citing polls showing strong bipartisan support for empowering Medicare to negotiate drug prices. House Democratic leaders still see the infrastructure package as their best chance of passing major drug reforms, despite concerns raised by the moderate members, a senior aide said.

“House Democrats in the previous Congress, when they enjoyed a larger majority, passed H.R. 3 almost entirely along party lines. The legislation went nowhere in the Senate, which was then controlled by Republicans, and former President Donald Trump opposed the bill. But many Democrats campaigned on the bill last cycle, showcasing it as an example of what the party could achieve if it won full control of Washington.”

Because the Democratic majority in the House is so slim, lawmakers are approaching legislation with an eye on the elections next year.  Democrats, especially those facing tough reelection fights in swing districts, will face enormous pressure from the powerful drug lobby to oppose the bill.

Instead of the sweeping legislation supported by the House Democratic leadership they have indicated supported for more modest measures that already have some Republican support.  Those include things like capping Medicare enrollees’ out-of-pocket drug costs.

Again, according to the Politico report, “Several of the moderate Democrats expressing reservations about the drug pricing bill are the targets of a $4 million-plus campaign by the conservative American Action Network opposing the legislation. The group plans to air ads in the districts of more than 40 Democrats, slamming H.R. 3 as “Nancy Pelosi’s socialist prescription drug takeover plan” and warning it would ‘cancel new cures for the patients who need them and send American innovation overseas.’”

Last year the Senate was a bigger problem when dealing with passing legislation but there still may be hope this year for a bi-partisan bill authored by Senators Ron Wyden (D-Ore.) and Chuck Grassley (R-Iowa).  “The bill would cap seniors’ drug costs and penalize drugmakers for raising prices too fast — a provision that many Republicans have likened to price controls. It would save the government a projected $95 billion over a decade, far less than the $450 billion-plus under the House negotiation bill,” according to Politico.

Legislation to lower prescription drug prices is a top priority of TSCL’s this year and we continue to monitor things very closely and work to pass legislation that will lower drug prices in a substantial way.

Hearing for pricing of Anti-inflammatory Drug Humira and Cancer Drug Imbruvica

On Tuesday of this week Rep. Carolyn B. Maloney, the Chairwoman of the Committee on Oversight and Reform, will hold a hybrid hearing to examine the pricing and business practices of AbbVie Inc., which sells the anti-inflammatory drug Humira and the cancer drug Imbruvica.

Humira is the best-selling drug in the United States and the world.  Since launching Humira in 2003, AbbVie has raised its price 27 times.  Humira is now priced at $2,984 per syringe, or $77,586 annually—a 470% increase from when the drug entered the market.

AbbVie, and its partner Janssen Biotech, Inc., have also raised the price of Imbruvica nine times since launching the drug in 2013.  Today, Imbruvica is priced at $181,529 per year for a patient taking three pills per day, as compared to $99,776 per year at launch.

The committee began its investigation into the pricing policies of 12 drug companies that sell 19 of the costliest medications for patients, consumers and taxpayers in January of 2019.  It sent requests for information on price increases, investments in research and development, and corporate strategies to preserve market share and pricing power for their products.

All of the companies were sent follow-up letters in June of that year requesting voluntary compliance with the Committee’s requests.

However, a third letter was sent only to AbbVie warning that its responses were “woefully inadequate” and that the Committee would consider a subpoena if the company failed to provide complete responses.

On September 1, 2020, Chairwoman Maloney notified all Committee Members of her intent to issue a subpoena to AbbVie if they continued to stonewall the Committee’s investigation.  After this notice, AbbVie finally began producing long overdue materials in response to the Committee’s requests.

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Despite the coronavirus emergency, TSCL is continuing its fight for you to protect your Social Security, Medicare, and Medicaid benefits.  We have had to make some adjustments in the way we carry on our work, but we have not, and will not stop our work on your behalf.

For progress updates or for more information about these and other bills that would strengthen Social Security and Medicare programs, visit the our website at www.SeniorsLeague.org, follow TSCL on Twitter or Facebook.