ARLINGTON, Va. — The “untenable” procedures around direct and indirect remuneration fees (DIR fees) can be righted with measures reducing costs for beneficiaries and the government, while promoting a more quality-driven health care system, says the National Association of Chain Drug Stores.

NACDS expressed that message in comments to the Centers for Medicare & Medicaid Services (CMS) recommending pro-patient and pro-pharmacy policies as the agency considers Medicare Part D prescription drug program changes for contract year 2019. CMS’ proposed rule involves e-prescribing, medication therapy management, opioid abuse and fostering pharmacy access, as well as DIR fees.

Steve Anderson

“NACDS’ comments reflect extensive member engagement, collaboration and consensus on highly complex issues which directly affect pharmacy operations and pharmacy patient care,” said president and chief executive officer Steve Anderson. “We appreciate CMS’ clear recognition of many of the topics that NACDS has raised on a consistent basis, and we appreciate this opportunity to share additional input.”

The association acknowledged CMS’ understanding of pharmacies’ concerns about DIR fees, such that “retail pharmacies must conduct business in an environment where they are unsure if a reimbursement they received is the final reimbursement or if a fee will be applied to them at some future point.”

NACDS’ recommendations for the fees cover: the factors involved in determining beneficiary payment and pharmacy reimbursement at the point of sale; implementation of a meaningful and consistent pharmacy-specific, pharmacy-based quality incentive program; a cap on performance-based fees; and further guidance from CMS to foster greater transparency and consistency in the use of fees and incentives.

The National Community Pharmacists Association (NCPA), which endorsed CMS’ plan to consider assessing DIR fees at the point of sale, meanwhile has drawn strong congressional support for its call to end retroactive fees. NCPA said that a bipartisan group of 80 representatives and 21 senators had endorsed a proposal to bring the fees to the point of sale. And more than 115 health care organizations signed a letter supporting such a move.

“We commend CMS for addressing in this proposed rule troublesome practices in the Part D program and encourage the agency to implement these provisions to produce greater convenience and savings for Medicare beneficiaries and greater transparency and fairness for pharmacies,” commented NCPA CEO B. Douglas Hoey.

“NCPA and its allies urge CMS to stand firm against pushback from PBMs, who oppose having pharmacy price concessions rolled into the initial adjudication process for prescription drugs, even though doing so is in the interest of patients who need the Part D benefit the most.”

The Pharmaceutical Care Management Association (PCMA), which represents PBMs, expressed concern with CMS’ point-of-sale pharmacy price concession ideas, “which put at risk the affordability and choice of preferred pharmacy plans — the most popular and widely chosen plan options in Part D.” Three-fourths of seniors are enrolled in Part D plans with lower-cost pharmacy options, PCMA noted.

“The fundamental problem is these ideas focus on micromanaging how plans use existing price concessions for Medicare beneficiaries, but do nothing to reduce high prices set by drug makers and imperil efforts to improve pharmacy performance,” PCMA said. “We see no way to implement the ideas … without increasing costs to the program and most of those it serves.”