Pharmacists should be able to freely tell patients that a drug will cost less out-of-pocket.
This article first appeared September 05, 2018 on Medpage Today.
By Shannon Firth
WASHINGTON -- Members of the House stumped for a healthcare bill that they said will improve transparency for patients at the pharmacy counter, and reduce their out-of-pocket costs, during a hearing Wednesday.
"Gag clauses" prevent pharmacists from informing patients that a drug will cost less out-of-pocket than it would using the patient's insurance, unless the patient requests the information directly, explained Rep. Michael Burgess, MD, (R-Tex.), chair of a subcommittee to the House Energy & Commerce Committee.
Rep. Buddy Carter (R-Ga.) put forth a draft version of a bill that would ban Medicare and private health plans from including gag clauses in contracts. Burgess called the bill "essential in both lowering drug costs for individuals and freeing the pharmacists to do what many consider the right thing."
At the hearing, Hugh Chancy, RPh, a member of the board of directors for the National Community Pharmacists Association, described a situation where gag clauses on patient-pharmacists discussions directly impacted his work. Chancy owns multiple pharmacies in South Georgia.
Chancy said a pharmacy customer, the mayor of a city in Georgia, was told that his co-payment for a single medication had increased from $7 to $26, after his city changed insurance providers.
Chancy said he told the customer that paying out-of-pocket for the medication would be less than the co-payment through insurance. The mayor then complained to the insurance company about the cost difference, according to Chancy.
The insurance plan contacted its pharmacy benefits manager (PBM) who issued a "verbal warning," claiming that Chancy had violated a contract by discussing the drug's cost without insurance and "disparaging the plan," he told the subcommittee.
"We were told [that] if my pharmacy were to do so again, there would be consequences," Chancy said, including being cut out of certain PBM networks.
David Yoder, PharmD, MBA, executive director of Member Care and Benefits for Blue Cross Blue Shield Association (BCBSA) Federal Employee Plan, said BCBSA does not support gag clauses, and even recommended that pharmacists go a step further in advising patients on generic substitutions, while stressing the need for "direct communication" with the prescribing physician.
He noted that he's "unaware of any Blue Cross and Blue Shield company or contracted pharmacy benefit managers to have gag clauses in place with pharmacies."
But Yoder's support for banning gag clauses was tempered by a warning regarding potential drawbacks of patients' not using their insurance to pay for prescription drugs. He noted that drugs purchased without insurance won't count towards a patients' deductible or out-of-pocket limits, "which may reduce the value of their insurance coverage."
Rep. Jan Schakowsky (D- Ill.) said she supported ending gag clauses, but noted that the committee needs to be doing more, such as advancing bills to allow Medicare to negotiate directly with drug companies.
Congressional members discussed a few other key pieces of legislation at the hearing:
- The ACE Kids Act that would allow states the option to create "health homes" for children with medically complex conditions, and to improve care coordination including allowing states to coordinate care with out-of-state providers.
- An amendment to title XIX of the Social Security Act aimed at broadening the authorities of State Medicaid fraud and abuse units, and allowing them to investigate and prosecute incidents where Medicaid beneficiaries may have been abused or neglected in any setting.
- The EMPOWER Care Act, which would reauthorize the Money Follows the Person Rebalancing Demonstration Grant. This allows states to help residents transition from institutions, such as nursing homes, into home and community settings using supplemental benefits not traditionally provided by Medicaid.
When asked about the consequences of not passing the EMPOWER Act, hearing witness Matt Salo, executive director of the National Association of Medicaid Directors, said "Without extension of Money Follows The person, what you're going to have is a definite subset of people who are in an institution ... who don't want to be there, who don't need to be there, and are going to have an enormous difficulty making the transition out."
Witness Rick Merrill, president and CEO of Cook Children's Healthcare System, expressed support for the ACE Kids Act, noting that some states don't have a children's hospital or lack access to high-level services. This legislation would help these children with very complex illnesses get care.