Written and published by Ross Snyder – Foundation Systems, Inc (801) 785-7720
ross@fsi.us.com – help.fsi.us.com – training.fsi.us.com
Light at the end of the tunnel
The “Pharmacy DIR Reform To Reduce Senior Drug Costs Act” is a small step toward helping the independent community pharmacy with being able to, at the very least, see actual DIR fees at the prescription point of sale/claim adjudication. The MA-PD (Medicare Advantage plan – Prescription Drug plan) or PDP (Prescription Drug Plan sponsor) will have to be transparent about the DIR fee, upfront, at the “point of sale”.
The idea behind this reform bill isn’t to do away with DIR fees but to create transparency. Don’t shoot the messenger! If it were me, I would write an act to eliminate DIR fees. In my opinion, DIR fees should be illegal. When you don’t get reimbursed according to your contract with an MA-PD or PDP, you can’t audit them and make them pay the difference according to your contract. You can’t go back and charge them for allowing you to process claims to them. What standard of performance measures are they held to? What are their star ratings?
Requests for a DIR estimation tool
According to NACDS, this bill takes effect on January 1, 2024. FSI considered developing a DIR estimation tool for claim adjudication. FSI watched this bill from the early stages and decided the development of such a tool would only have value for a short time. Knowing our customer base is independent community pharmacies, we partnered with FDS Amplicare, giving each of you the DIR tools without further expensive and time-consuming development. Although the tool offered by FDS Amplicare isn’t real-time, it’s the next day. However, your pharmacy would have a way to keep track of estimated DIR fees until this reform act takes effect. With the information we now have and a time frame, FSI is excited for the new reform act to kick in! We will be ready to provide the information in real-time as soon as the MA-PD or PDP sponsor responding starts transmitting it back.
Standardized pharmacy performance measures will continue
The future of DIR reform will still be performance-based; click the link below to read the complete reform act. Below the link is a section of the act addressing the continuation of performance-based DIR fees.
DIR fees aren’t going away, just becoming transparent at the time of adjudication.
Click the link above to read the complete reform act.
This portion of the reform act discusses the performance measures, something you should already be familiar with:
(B) STANDARDIZED PHARMACY PERFORMANCE MEASURES. —
“(i) IN GENERAL.—Notwithstanding any other provision of law, the Secretary shall establish or adopt standardized pharmacy performance measures from one or more multi-stakeholder, consensus organizations representing all pharmacy types (including specialty pharmacies) to be used by a PDP sponsor and MA–PD plan for the purposes of determining incentive payments and price concessions described in subparagraph (A). Such measures shall be evidence-based and focus on pharmacy performance on patient health outcomes and other areas, as determined by the Secretary, that the pharmacy can impact based on covered part D drugs dispensed and managed.
“(ii) MAINTENANCE OF LIST.—The Secretary shall maintain a single list of measures established or adopted under this subparagraph and measures shall be evaluated and updated on an ongoing basis through stakeholder consensus organizations to ensure they are transparent, achievable, and clinically meaningful.
“(iii) APPLICATION TO STAR RATINGS. —The Secretary shall require the development of measures to apply in the star rating system under this part to assess the use of a standard set of pharmacy performance measures by PDP sponsors and MA–PD plans.