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Medicare Rules for Antidepressants Could Draw More Scrutiny

By Kerry Young, CQ Roll Call
March 7, 2016 -- Advisers to Congress are rekindling a debate over whether Medicare can mimic a common tactic that private insurers use to limit drug price increases, wading into a controversial topic amid rising concerns about the cost of pharmaceuticals.
The Medicare Payment Advisory Commission last week resurrected the idea of of eliminating some of the six so-called protected classes of medicine in the Part D prescription drug program, a proposal Medicare officials discarded two years ago. MedPAC intends to offer recommendations on prescription drugs in its June report to Congress.
The insurer-run plans now much cover substantially all of the medicines available for six conditions: seizures and epilepsy, cancer, certain viral infections, depression, psychosis, and the prevention of rejected transplanted organs.
The Part D program is projected to cost roughly $98 billion this year, according to Medicare trustees, making it one of the single biggest federal health expenses and one of the nation's largest buyers of medicines. MedPAC staff last week suggested cutting antidepressants and transplant medicines from the list of protected classes of medicines in the drug program. The suggestion is part of a package of draft recommendations on the Part D program that the commission will vote on next month. 
The revival of the idea may be a sign of the growing interest in Washington in addressing rising drug costs.  The Centers for Medicare and Medicaid Services in January 2014 proposed eliminating antidepressants, psychosis and immunosuppressants used for transplant patients from the coverage mandates. By May 2014, CMS had backed off the proposal due to a considerable backlash. The proposal is likely to continue to draw opponents, said Juliette Cubanski, associate director of the program on Medicare policy at the nonpartisan Kaiser Family Foundation, in an interview Monday. 
“It’s a fair question of whether MedPAC would be showing any interest in this type of idea were it not for the pressing concern that many people have about rising costs for prescription drugs,” Cubanski said.
A Kaiser Family Foundation poll last year found that 63 percent of respondents thought government action to lower prescription drug prices should be a priority for lawmakers and the next president.
The proposed changes to the Part D program are meant to increase the insurers’ bargaining clout for the medicines in question. Insurers routinely seek to bargain with drug companies by dictating terms for covering their medicines, weighing in pricing factors when the perceived benefits of products are similar.
“They basically have no ability to do any sort of negotiations with drug companies” for medicines in the protected classes in Part D, Cubanski said. “That really is their leveraging tool, to include some drugs and not others.”
The Partnership for Part D Access, a coalition of patient advocacy, industry groups and companies such as Johnson & Johnson, last week objected to MedPAC’s decision to raise again the suggestion of cutting back on the protected medicine classes.
“Restricting timely access to medicine jeopardizes patient health, puts patients at greater risk for poor clinical outcomes, and increases costs for patients and taxpayers, said Chuck Ingoglia, senior vice president of the National Council for Behavioral Health and executive director of the Partnership for Part D Access.
Separately, Sen. Charles E. Grassley last year introduced a bill (S 648) that would codify the initial approach CMS took in creating the six protected classes of medicines. It has two cosponsors, both Democrats.

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