Notes from Joe
Improving Access to Care While Lowering Costs
By Joe Pugliese
All of the recent news, including the hearings about our potential new Supreme Court Justice, highlight that people are worried, concerned, and fixated on the cost and access to health care and of course, since it’s an election year, people want to know who to blame. The short answer is all of us, but then it gets more complicated.
As the chart below highlights – the cost of healthcare has not slowed down in any detectable fashion. The average premium for family coverage has risen 55 percent since 2008 — about twice as fast as wages, which are up 26 percent, and three times as fast as inflation, up 17 percent over a decade.
The cost of care raises access issues not just for the hemophilia community but for everyone. Historically the community has focused on access but been silent on the cost of care. I would argue that unless you have unlimited resources (typically expressed as dollars), there is a direct link between the two. It may not manifest itself in your specific situation, but if you spend $1,000,000 when you could have done just as well spending $700,000, someone suffers.
It certainly is not that we do not spend enough money on healthcare; as the chart below shows we out spend everybody by a wide margin. Despite this we get worse results also by a wide margin compared to Organization for Economic Co-operation and Development (OECD) countries, which includes Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom. It is not that we need to try to do more with less, it is we should be doing more with the more we already spend.
Several years ago, I met with a former Medicaid Director to get advice on how to approach his state to include HTCs as providers. I explained how utilizing the HTC network as one of the pharmacy providers could save the state more than $8 million on 400 patients. Of course, it would also provide much needed funding for the comprehensive care model, which is clearly the gold standard for treating bleeding disorder patients. He said and I paraphrase, “do you know how big my budget was (insert 100s of millions of dollars)? Saving $8 million would not be worth my time.” I think that comment neatly summarizes why we spend so much and get relatively little for the money we spend. The $8,000,000 would buy 400 families of four health insurance for a year. If the hemophilia community paid $.01 less per unit and passed that penny on, we would save $50,000,000 per year or buy health insurance for 2,631 families.
We do not need Congress to pass a bill and we do not need the executive branch to try to impose dramatic new drug pricing policies. What we could do starting tomorrow is insist that patients be able to access treatments at a federally-supported HTC. Today, HTCs have about 20-25% of the market, despite providing clinical care for nearly 100% of the most severely affected patients, and despite the fact that the payer team routinely can show brokers and health plans savings of 20-30% over the specialty pharmacy that is presently shipping replacement product to the patient. If we could simply double our present market, which by the way would help fund expanded staffing and services to benefit even more patients with more bleeding disorders, we could reduce annual costs of care by $80,000 x 4,000 patients or $320 million, which would buy 16,842 families health insurance for a year. We would not have to switch products; we could keep and the strengthen the comprehensive care team that patients rely on for care.
What we DO need Congress and agency policymakers to do is to support the original intent of the 340B program, which is to stretch scarce federal resources and help fund clinical care. For the rest of the year, I’ll share more specific ideas of what we need to be doing. If you have any ideas, please share them with me.
The ABCs of Indirect Cost Rates
By Elizabeth "Issie" Karan
HTCs often inquire with the Hemophilia Alliance regarding what is an appropriate “indirect cost rate.” I put this term in quotations because it goes by many names, facilities & administration fee, overhead charges, etc. Anytime I, as an amateur accountant, confer with true number crunchers, I find it important to make sure that we are discussing the same things. What I mean by “indirect cost rate” is the definition used by the Uniform Grants Guidance (UGG), codified at 45 CFR Part 75. However, what your grants manager, business manager, or pharmacy director means may differ. So, as you have internal conversation, I encourage you to make sure you are discussing the same costs.
Two important sets of rules govern how an HTC budgets and reconciles its books: the UGG and your organization’s rules. Sometimes the grant rules may be more prescriptive; other times your organization may have its own strict rules. As such, it is important to understand when and how both sets of rules govern your HTC’s operations.
As for “indirect cost rates”, the UGG defines the term differently for different types of grantees at §75.414. Major institutions of higher education are defined as those required to use the Standard Format for Submission as noted in appendix III to part 75.C. 11. Major nonprofit organizations are those which receive more than $10 million dollars in direct Federal funding.
For major institutions of higher education and major organizations, indirect (F&A) costs must be classified within two broad categories: “Facilities” and “Administration.” “Facilities” is defined as depreciation on buildings, equipment and capital improvement, interest on debt associated with certain buildings, equipment and capital improvements, and operations and maintenance expenses. “Administration” is defined as general administration and general expenses such as the director's office, accounting, personnel and all other types of expenditures not listed specifically under one of the subcategories of “Facilities” (including cross allocations from other pools, where applicable). For nonprofit organizations, library expenses are included in the “Administration” category; for institutions of higher education, they are included in the “Facilities” category.
Because of the diverse characteristics and accounting practices of nonprofit organizations, the UGG states that it is not possible to specify the types of cost which may be classified as indirect (F&A) cost in all situations. Identification with a Federal award rather than the nature of the goods and services involved is the determining factor in distinguishing direct from indirect (F&A) costs of Federal awards. However, typical examples of indirect (F&A) cost for many nonprofit organizations may include depreciation on buildings and equipment, the costs of operating and maintaining facilities, and general administration and general expenses, such as the salaries and expenses of executive officers, personnel administration, and accounting.
As for general rules of thumb for indirect cost rates, please see this letter from the Maternal and Child Health Bureau to then Program Directors of the MCHB Hemophilia Regional Grant, describing how HTCs should approach indirect cost rates. Additionally, this letter from the Maternal and Child Health Bureau, dated 1996 stating that the average indirect cost rate charged to HTCs was approximately 8.25%.
By Johanna Gray
With waning days before the election, all eyes are turning away from Washington and towards the voting booths of Americans across the country. I hope that everyone is getting organized to vote in a few weeks and in the meantime, I’m pleased to provide a brief Washington update:
- Federal Funding: Because it was unable to pass the regular federal funding bills before the start of fiscal year 2021 on October 1st, Congress passed, and President Trump signed into law a continuing resolution (or CR) to extend last year’s funding levels until December 11, 2020. This gives Congressional leaders a few more months – and gets them past the election in early November – to negotiate bills to fund the government. Congressional leaders say that they are going to start working and negotiating new bills before the December deadline, but there is also a good chance that they will either do another CR either for a few months until the start of the next Congress (and potential change in Presidential administration) in January, or for the full year. One note is that your HTC grants may come in pieces since full year funding has not yet been approved.
- Public Health Emergency Extended: Secretary of Health and Human Services Alex Azar recently extended the COVID-19 related public health emergency (PHE) for another 90 days, until mid-January 2021. That means that all of the waivers and new policies allowed during PHE, such as expansions for telehealth services in Medicare and Medicaid, will continue at least until then and of course, depending on the status as of January, it could be extended again. We’ll update the community as we get closer to the next expiration.
- Committee Leaders Seek Input on 340B Modernization: Senate HELP Chairman Lamar Alexander (R-TN) and House Energy and Commerce Committee Ranking Member Greg Walden (R-OR) recently put out a request for information seeking policy ideas from stakeholders about 340B reform. What’s interesting is that both Members of Congress are retiring from Congress as of the end of the year, so it’s not clear whether they’re trying one last attempt at 340B policymaking before they leave (though that will be difficult without support from Democratic leaders who do not appear to be involved in the effort) or trying to set up their successors to hit the ground running in the new Congress in January. The Alliance will be responding to the RFI before the deadline at the end of October and will share our letter with members once finalized.
Payer Trends: What You Need to Know
By Jeff Blake
Over the last few years, the Payer Team has established strong relationships with several national insurance brokers and consultants, stop-loss/reinsurance carriers, insurance companies/third party claims administrators and mid-tier pharmacy benefit managers. These payers and advisors work with employers, many offer self-insured health plans, to manage their health plan expenditures and design.
So, what have we learned over the last few years and what are some of the trends?
- Employers continue to focus on enhanced management of high cost complex claims – including bleeding disorders. All eyes are on HTCs, products prescribed and dispensing pharmacy practices.
- Many manufacturers are providing rebates for clotting factor to health plans and PBMs and commercial specialty pharmacies are able to lower their reimbursement rates with payers to be more competitive with HTC pharmacies. If this trend continues HTC pharmacies may need to reduce their reimbursement rates with payers.
- Payers are now requiring performance guarantees with penalties in their contracts with HTCs. Guarantees include Assay Management and avoidable emergency department visits. We were recently asked to include an Assay Management guarantee in an individual Letter of Agreement (LOA).
- Bleeding disorders product pricing and reimbursement rates are getting more competitive. Our competitors want to grow their business just like our member HTC pharmacies. The rates our competitors are charging payers continues to decrease, so HTC pharmacies must continue to review their bleeding disorders reimbursement rates to remain competitive.
- Self-insured employers and their brokers/consultants are very willing to work with HTCs and their pharmacy programs to reduce the cost of the bleeding disorder medication. Many times, this requires an individual Letter of Agreement (LOA) between the employer’s health plan and the HTC.
- The Hemophilia Alliance Team typically receives 3 – 5 broker/consultant requests each week to evaluate potential savings by moving the bleeding disorders medication from a commercial specialty pharmacy to a member HTC pharmacy. Below are additional items we have determined in our work with these brokers/consultants:
- 5% – 10% of the time the HTC and their pharmacy program are already providing the clinical and pharmacy services. No changes are necessary – the employer has the best deal.
- The remaining 90% – 95% of the time there is an opportunity for the HTC and their pharmacy program to get new business.
- When the Hemophilia Alliance and the HTCs can respond to these opportunities quickly (within 5 – 10 business days) and with competitive pricing for the bleeding disorders medication, we are more likely to win the business for the HTC pharmacy.
- When it takes us longer than 2 weeks to respond, their interest in our response has significantly declined and they have moved on to other hot items. Often, we cannot get them re-engaged in our proposal.
- If your HTC is operating its pharmacy program exclusively through contract pharmacy arrangements with pre-determined pricing, consider signing a contract pharmacy arrangement with The Alliance Pharmacy (TAP). This provides a low-cost option for administrative services but more importantly creates an opportunity to offer flexibility in product pricing as the payer team helps your HTC acquire business.
- The payer community has gained an enhanced understanding of the HTC model of care and how integrating the medical care with the HTC pharmacy can improve outcomes and save money.
- Payers continue to gain interest in contracting with Hemophilia Alliance Network Services (HANS). We now have 4 payer contracts – CareSource, ArchimedesRx, AscellaHealth and Security Health Plan and we are working with several other payers on potential HANS contracts. If your HTC has not signed the HANS PPO agreement to participate in HANS payer contracts, now is an excellent time to sign up.
If you would like additional information about the HANS PPO Agreement and our payer relations activities, please contact a member of the Hemophilia Alliance Team. We Work for You!!
Community Relations Update – October 2020
By Karen Bowe
As announced in August, we have launched our new campaign, Harmony in Hemophilia, aimed at enhancing relationships between our member HTCs, NHF Chapters and HFA Member Organizations. The goal driving our efforts is to facilitate increased awareness of all organizations and positively affect collaboration between the groups.
As a result, I wanted to make you aware of our upcoming first series of joint webinars. On October 21st, the Hemophilia Alliance and HFA held a joint webinar aimed at increasing awareness of both organizations, as well as an overview of Hemophilia Alliance Foundation and The Alliance Pharmacy. The target audience for this webinar was member HTCs, HFA leadership and HFA members.
In addition, on November 5th at 3pm EST, the Hemophilia Alliance will join with NHF to present HTC testimonials entitled “Working with your local Chapter”. Several of our member HTCs have offered to present at this webinar and I’ll be reaching out to them in the very near future to discuss further. Target audience for this joint webinar will be member HTCs, NHF and HFA leadership, as well as members of both organizations.
If you or your Center have any suggestions for future joint webinars, please reach out to me at firstname.lastname@example.org or at 717-571-0266. I’ll be more than happy to discuss how we can make your interactions with your local Chapters more meaningful and helpful to your patients.
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Join Our Growing Hemophilia Alliance Team!
By Sean Singh
As we grow and are navigating an ever-changing virtual world, the Alliance is looking to hire an IT person, who ideally also has some experience in the bleeding disorders community. The position will report to the Senior Vice President of Marketing and Operations. The job description and requirements can be found here. For questions about this position, please contact Sean Singh at email@example.com or 727-388-7326.
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Meeting Schedule for 2021
Spring Members Meeting – Virtual
Hill Day – Virtual
Linda Gammage Social Worker Conference – Fall
New HTC Staff Meeting – Fall
Fall Members Meeting – September 2021
Team Alliance Contact Information
We work for you! Please don’t hesitate to contact any of us with any questions or concerns: