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The Dangerous Link Between DIR Fees and Catastrophic Coverage—and How It’s Hurting Patients and Pharmacies

Posted on in Industry Updates by Amplicare Team

On the surface, catastrophic healthcare coverage is a great thing. For the 44.5 million Medicare beneficiaries1 enrolled in the Part D program for self-administered prescription drugs, this coverage phase is designed to make out-of-pocket costs manageable, once drug spending crosses a certain threshold. Without it, many patients with chronic health conditions would not be able to access their medication. 

But something has gone horribly wrong. While catastrophic coverage offers a helpful cushion for the patients with the most dire needs (relatively few), beneficiaries compelled into catastrophic coverage have risen sharply2 in recent years—going from 515,000 to more than 800,000 between 2013 and 2016. 

And this isn’t happening because the population is getting sicker. Pharmacy direct and indirect remuneration (DIR) fees, which are adjudicated retroactively by pharmacy benefit managers (PBMs), are one of the factors pushing patients into the coverage gap, and subsequently catastrophic coverage, much faster than the system intended.

On the brink of catastrophe 

For 2018, Medicare patients enrolled in the Part D program hit a temporary limit on their coverage3 after the total cost of their drugs reaches $3,750. At this point, they enter the coverage gap—otherwise known as the donut hole. Once in the donut hole, the patient’s out-of-pocket costs skyrocket, until the patient enters catastrophic coverage.

Once the patient’s total out-of-pocket4 costs reach $5,000, they enter the catastrophic coverage5 phase. At that point, the government steps in to saddle 80% of costs, with patients rounding up the difference (5%). That means the insurer is left covering just 15%, versus the 75% they cover during the initial coverage phase. 

And therein lies the incentive. 

DIR fees and the donut hole

In theory, DIR fees are intended to bring Medicare costs down and improve pharmacy services. In reality, they force pharmacies to spend more on the medications they stock and dispense, increasing out-of-pocket costs for patients and ultimately driving Medicare costs up over time.

The problem stems from the fact that DIR fees are almost always applied after the point-of-sale. For pharmacies, it’s common for weeks or even months to go by before they know what percentage of the prescription costs the PBM will claim. The retroactive nature of DIR fees make them unpredictable, leaving pharmacies across the county struggling to plan budgets and forecast margins and cash flow.  

Since patients’ copay percentage is based on point-of-sale cost (vs. adjusted cost), they don’t necessarily benefit from discounted drug prices. And even though DIR fees translate into lower payments for insurers, it’s the non-discounted drug price that counts toward the patient reaching their coverage limit. 

This pushes patients toward their coverage limits faster, causing them to enter first the donut hole and then catastrophic coverage sooner.

Encouraging transparency. Improving outcomes. 

Increasing transparency around DIR fees at the federal level is the best way help pharmacies stay in business and protect patients from unbalanced out-of-pocket costs. Right now, three bills pending in Congress aim to do just that: S.4136, H.R.13167, and H.R.19398. Support these bills today by contacting your local Member of Congress. 

At Amplicare, we’re dedicated to helping pharmacies navigate Medicare Part D efficiently and effectively to provide the best care to your patients. To learn more about how we can help, visit Amplicare.com/imedicare or contact us today. 

https://www.hhs.gov/about/budget/fy2017/budget-in-brief/cms/medicare/index.html
http://avalere.com/expertise/life-sciences/insights/more-medicare-part-d-enrollees-are-reaching-catastrophic-coverage
https://www.medicare.gov/part-d/costs/coverage-gap/part-d-coverage-gap.html
https://q1medicare.com/PartD-WhatIs-TheTrueOutOfPocketExpense.php
https://www.medicare.gov/part-d/costs/catastrophic-coverage/drug-plan-catastrophic-coverage.html
https://www.congress.gov/bill/115th-congress/senate-bill/413/all-info
https://www.congress.gov/bill/115th-congress/house-bill/1316
https://www.congress.gov/bill/115th-congress/house-bill/1939

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