The upcoming changes to reimbursement rates and Direct and Indirect Remuneration (DIR) fees are causing concern among pharmacists. The Center for Medicare and Medicaid Services (CMS) will implement new rules at the beginning of 2024, eliminating retroactive application of DIR fees by pharmacy benefit managers (PBMs). Instead, these fees will be included in the negotiated price paid by patients at the pharmacy counter. While CMS aims to enhance transparency, some worry about potential challenges.
Frier Levitt attorney Steven Bennet was recently quoted in Drug Topics article “Upcoming DIR Fee Changes Still Causing Concern for Pharmacists” by Keith Loria.
In this article, Steven emphasizes that overall reimbursement for pharmacies will decrease, with few exceptions. He also notes that new performance programs funded by pharmacy fees from PBMs have limited adoption due to CMS’s stance on these fees.
Pharmacies should be prepared for heavy negotiations with PBMs either directly or where applicable with their pharmacy services administrative organization (PSAO). Specialty pharmacies negotiating 2024 Medicare Part D contracts should work closely with their PSAO to secure favorable rate concessions. He states, “Pharmacies should always be aware that their PSAOs are responsible for negotiating the best possible contracts with PBMs…[A]PSAO chooses whether or not to accept the terms offered by PBMs, pharmacies should be discussing these decisions with PSAOs and offering feedback regarding those choices.” Pharmacies and PSAOs that leverage their position in the marketplace can obtain better contract outcomes.
Direct negotiation is not the only means for pharmacies to secure a reasonable marketplace. Frier Levitt advocates for relief for all pharmacies through amendments to the Part D Act and urges individual pharmacy owners and associations to continue putting pressure on their legislators to vote in favor of such legislation.
“With respect to political changes, every voice being raised to every politician in Congress is necessary to see positive legislative for pharmacies,” Steven said. “Members of Congress take seriously feedback from their constituents and the more they hear their constituency agreeing on reimbursement relief for pharmacies, the more of a priority that issue becomes. It is crucial that pharmacies continue to write emails and letters, and to call the offices of their elected federal officials, to push for reform.”
Frier Levitt can assist PSAOs and providers with PBM contract negotiations as well as outreach to elected officials to effectuate positive outcomes in the healthcare marketplace. Reach out today to learn more.
Read the Drug Topics article here.
