The bigger question can be whether HHS will need to get congressional approval in order to change the way which government pays for drugs in Part B. Under current law, the government pays full list cost for those branded drugs — which are administered by physicians through injections or infusions — plus a 6 percent markup for physicians.
“Medicare, when the idea was set up, was built on the product which was essentially, ‘Tell us what the idea cost as well as also we’ll pay you,’ … a cost-based reimbursement product,” which can be why the government doesn’t negotiate prices under Part B, David Hyman, a professor at Georgetown University Law School explained.
Medicare Part D drug plans were enacted as part of the Medicare Modernization Act of 2003 as well as also were set up under a private market product in which pharmacy benefit managers can negotiate discounts.
“You can’t merge Part B into Part D from the big-picture sense of the idea without getting Congress to enact amendments to either of the pieces which adopt them,” explained Elizabeth Mann, an attorney with Mayer Brown, who co-leads the law firm’s health-care practice.
Getting a bill passed to overhaul the program completely could be a tall order, politically. However, the administration could make substantial modifications to Part B through regulatory authority, according to Mann.
“CMS could write a set of regulations which I think permit the buying efficiencies of Part D to be made available from the Part B universe,” she maintained, adding, “I think they could come up with any number of tools which might permit or require … (doctors) purchase (drugs) at the lowest-cost seller. as well as also the lowest-priced seller could be the Part D administrators.”
If the idea’s which easy, why hasn’t the idea been done before? Georgetown’s Hyman thinks the idea’s because such a move might likely go beyond the administration’s regulatory authority as well as also might certainly be challenged in court.
“the idea will be much more straightforward as well as also legally defensible to say ‘we’re going to do a demonstration on the following drug’ where we want to figure out whether This specific will actually work,” Hyman said. “You want to pick ones where you think you’d have an impact.”
He said the administration could set up a demonstration through the Centers for Medicare as well as also Medicaid’s innovation center, targeting high-priced brand-name drugs in Part B which have lower-priced competitors, which are equally effective.
“which’s not just low-hanging fruit, although fruit which’s lying on the ground, waiting to be picked up,” he said.