Elliott Warren   1:31:12
Well, you know, at least for Part B, because obviously these MFPs DO NOT go into effect. They're not effectuated until January the 1st of 2028. It is, it is not in place. I can't tell you what some of the conversations on what certain payers are thinking at this point, but you know the IPA continues in our advocacy efforts to highlight the fact that this is going to have severe and tremendous and disruptive impacts. John, do you have any additional color on that?

John McManus   1:31:50
I think that's fundamentally right. We don't know the answer yet because this hasn't gone into effect. So the rule that was announced in 2026 impacts the product for 2028. So at this point we don't know how the commercial contracts will deal with this. Maybe they take some index.

John McManus      1:40:14
It's a great question. There's not really a good policy answer. It's just that these fee schedules have developed independently in silos over time and their payments are updated differently and they're both budget neutral to themselves. So for example.

In the hospital outpatient sector, it's everything that the hospitals provide. It could be drug infusions, it could be radiology, outpatient surgery, any number of things and those have to get those are changed over time and have to be budget neutral to themselves so that a volume goes up in one sector is decreased in another and physician fee scales are the same thing. So there's been a move away from specialist to primary care that's hurt the specialist providing many of those services.
And there's no rhyme or reason to it. And many of the policy analysts who focus on Medicare say this doesn't make any sense. There should be what's called site neutrality, pay the same amount for the same thing. And there's also concern, frankly, in the in the policy sphere that why should we tie reimbursement?

For administering these products to the price of the drug, it's a good question and the answer is, well, it's been ingrained that way for many years and it's hard to move away from it because even before ASP plus six was created, which I was involved in as I said at the outset of our discussion.

We have the average wholesale price, which was a list price, determine reimbursement for Part B drugs. So I think people would like to get to a more equal payment between the two sites of care and get away from overtime compensation that's related to the price, but that's going to take a lot of policy work and political consensus that has to be developed. And right now we've got a crisis on our hands that we're about to get massive cuts in less than two years.

Elliott Warren   1:42:41
I'm happy to to take that. It's a great call out. It's a good question. I will tell you it wasn't the focus of this conversation, but the vertical integration of commercial insurers who own the PVM who own the special.

Pharmacy in many instances, you know on the providers as well. It's a real concern for the IPA. White bagging in particular is something that we have taken a hard stance on. I will say that the significant majority of our members.
Fused a white bag as a matter of policy because of #1 the economics, but #2 just the inferior clinical outcomes that can result because of a number of those practices because of the fact that you know a white bag drug is individualized to that patient. It does not provide the provider the flexibility. Ability to adjust based on lab values or weight at the time of administration. The fact that there are documented practices of drugs being sent to the wrong address. And if you're an MS patient who's arranged childcare, you've taken time off work for two to three hour infusion. And you can't get your treatment. There's a real problem and that creates real clinical impacts, but also just quality of life issues. So the House Energy and Commerce Committee as well as the House Ways and Means Committee held a hearing in in January. You may have seen it. It was pretty highly reported in the press where they brought together 5 executives from some of the largest insurance companies. And there was a bipartisan focus on the fact that the vertical integration in this industry has caused real concern from providers, from patients, from policymakers.

The IPA submitted some pretty comprehensive comments ahead of that. It's on our website, but happy to make it available to folks specifically calling out white bagging practices as well as some of these self-administration requirements that certain insurers are requiring. You know the IPA's position on that is we fully support a patient being able to self-administer a product that the FDA label stipulates can be administered, you know, in the home by the patient if that is what they would like to do. But there are plenty of instances where patients are fearful of self-injection. They are fearful of adverse reactions. They don't have the cognitive or physical dexterity to self administer. In those instances, the decision on where and how to administer medication should be made by a patient in consultation with their physician, not dictated, not mandated by an insurance company. And so this is absolutely a focus of the IPA.

I will tell you that out, you know, there were some pretty comprehensive PBM reforms mostly in kind of Part D that were long time efforts. Those were enacted earlier this year in January.

As the Congress, as policymakers start to think about new healthcare priorities, IPA is absolutely elevating this issue of the vertical integration of many of these companies and the negative impacts on practice stability, on provider autonomy and certainly patient access and clinical outcomes. So it's absolutely a focus for us.

John McManus      1:53:25
There's lots of different quantitative firms around town trying to predict what's next. We do have. You know, there is public information on how much drugs cost or cost on the Medicare program, but these things change every year, so.  We've not been in the business of doing that, but I think Avelier and other firms like that are making those predictions.

It would apply to all to your second question. It would apply to all NDCS of that product. There is no exception to that. I did want to under score. We sort of skipped over what the legislative solution is here. It is this bill that that Elliott talked about, the protecting patient access to cancer and complex therapies Act. What that does is replaces the reimbursement cut to healthcare providers, whether they're physician practices, hospitals or freestanding Infusion centers, and it replaces that with a rebate.

Paid by the drug manufacturer, we know that most price concessions in the pharmaceutical sector for years have been rebates. So we've had the Medicaid rebate since 1991. Most commercial contracts are based on rebates.

John McManus      1:54:27
And even in the IRA, there's a rebate when the price exceeds the consumer price index. So what we're saying here is let's use that tried and true model of capturing manufacturer price concessions through a rebate that the manufacturer would pay.

The Medicare program pay CMS and providers will continue to get paid at ASP. So that rebate would cover both the price of the lower MFP price, the differential between ASP and MFP.

And would also cover the differential for the provider payment, that add-on payment and that would continue to be calculated at the higher rate and the the bill also specifies that there's the ASP would remain and and it would it would reverse the CMS.

Decision, as I said, not based in statute that only allowed the publication of the MF PS.