TennCare - Factor Medication Reimbursement Rates (CMS-2345-FC)

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Bleeding Disorder Patients and Specialty Pharmacies are seeking a correction to recent reimbursement changes promulgated by TennCare on April 1, 2017. The reimbursement methodology used for Blood Factor products has been radically altered in a way that is wildly out of line with other nationally-recognized benchmarks and indices.

The reimbursement now jeopardizes the care of all TennCare-covered lives with the rare genetic bleeding disorder commonly known as Hemophilia. The pricing is now well below the wholesale cost across all products, preventing the sustained business of providing even the most basic level of service to these patients. It is our contention that the reimbursement proposed by Meyers and Stauffer was irresponsibly promoted, containing fundamentally flawed premises and unsustainable scalability.

 These recent changes fail to satisfy the requirements of section 1902(a)(30)(A) of the Social Security Act mandating that their methods "assure that payments are consistent with efficiency, economy, and quality of care and are sufficient to enlist enough providers so that care and services are available under the plan..." The briefest review of Standards of Care will yield multiple recommendations across both lay and scholarly Hemophilia-specific publications that speak to the crucial support services necessary to prevent a cycle of preventable hospitalizations. See also the MASAC guidelines which can be found via the CDC website. These changes not only risk the morbidity and mortality of this patient population, but shifts and magnifies the cost to the healthcare system as a whole. These pricing changes fail to achieve the goals of sensible, fair reimbursement or preserving uninterrupted access to outpatient care.

This pricing methodology completely abandons such indices as WAC, AWP, MAC, and instead relies exclusively on voluntary "surveys" and "help desk calls". This proposed method is exquisitely susceptible to flawed data and flawed conclusions based on any such data. It is difficult to imagine a less statistically sound method for arriving at valid extrapolatable figures. Moreover, this non-indexed approach necessarily creates more work, potentially flawed, for the staff responsible for staying abreast of ceaseless pharmaceutical price increases.

Futhermore, included in TennCare's own Specialty Pharmacy Agreement distributed by Magellan on 11/4/16, are a litany of reporting requirements and extraneous services mandated for patients receiving Blood Factor products. The recent shift to a negative reimbursement model now denies pharmacies the resources to satisfy requirements such as "2.20) The Specialty Pharmacy shall provide therapy management and care coordination programs and services that may include, but are not limited to, the following:... [education, injection training, Registered Nurses]..." Again, this is in addition to a pricing model that suggests dispensing below cost. 

The new reimbursement model blithely ignores expenses incurred by the additional staffing necessary to perform the exhaustive reporting required by TennCare on patients receiving Blood Factor products. This financial burden is compounded by unrecouped cost unique to Specialty Pharmacy in general and Hemophilia management in particular. There are fees and staffing necessary to seek and maintain niche Specialty certifications in good standing with accrediting bodies such as JCAHO, URAC, CHAP, ACHC, and the like. 

In short, this patient population is now positioned to lose access to care. Any imagined cost savings will be vastly outweighed when the hospital bills begin rolling in. Please intervene in this matter before it results in a public health crisis.