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Dec. 21, 2018 (ACP)—As the clock ticks toward 2019, the �ܼ�����ˮ��̳ is urgently advising Congress to act to protect Medicare recipients from possible changes that would sock them with extra prescription costs when they're in what has become known as the Part D “donut hole.”

“ACP is supportive of the current phasing out of the ‘donut hole’ in 2019,” said Hilary Daniel, an ACP health policy associate who recently met with about three dozen congressional staffers to explain how best to protect patients moving forward. At the same time, ACP is also closely monitoring efforts to repair the so-called Medicare Part D “cliff,” a related topic that came up at the meeting.

“ACP was asked to attend to share the physician perspective, and I shared the experiences of ACP members who have dealt with patients falling into the donut hole and the impact that had on patients and their families,” Daniel said.

“These stories do not end simply with the patient being able to afford their drug,” she explained. “Drug affordability impacts whether or not patients actually pick up their medications from the pharmacy or if they adhere to their treatment as prescribed. Patients may resort to splitting or skipping pills, among other strategies for keeping costs down. This can result in patients developing more serious health conditions.”

The “donut hole” debate has to do with a new federal policy that kicks in next year: As a result of congressional action, the Medicare Part D “donut hole” will disappear for name-brand prescription drugs.

That means that, as of 2019, recipients will pay 25 percent of the cost of prescription drugs until they reach the catastrophic-coverage level. Now, they must pay 35 percent when they're in the “donut hole.” Also, drug companies will need to provide higher discounts on medications, starting in 2019.

Daniel said there's also concern that Congress will switch things up by reducing the drug company discounts.

In a letter to congressional leaders in mid-November, a coalition of health care organizations, including ACP, noted that “moving forward with such a proposal during the lame duck session would dramatically increase costs for seniors and taxpayers, who will be forced to subsidize what amounts to a multi-billion-dollar bailout for the price-gouging pharmaceutical industry.”

The meeting with congressional staffers allowed ACP and other groups to press their case.

“The topic of drug pricing is complex and multifaceted, and it can be a bit daunting to try to sort through all the data, charts and policies that make up how drugs are priced and paid for,” Daniel said. “Bringing it down to the patient level always brings people back and reminds them that drug pricing isn't just a hot topic of the moment or a list of numbers on a page. It has a real-world impact.”

ACP has not taken a position, Daniel said, on another issue that came up at the meeting – the fate of the “cliff,” the threshold at which the Medicare “donut hole” disappears and recipients begin paying no more than five percent of drug costs under a “catastrophic coverage” regimen.

An Affordable Care Act (ACA) provision “slowing the growth of the catastrophic coverage threshold expires after 2019, and the threshold reverts to its pre-ACA scheduled level,” according to the Center on Budget and Policy Priorities, a nonpartisan research and policy institute. “As a result, the threshold will jump from $5,100 in 2019 to $6,350 in 2020.”

A bill introduced by two Democratic members of the House “would eliminate the cliff by making the slower growth rate permanent,” according to the center.

Speakers at the meeting with congressional staffers said they believe that “fixing the Part D ‘cliff’ and keeping the changes made to the ‘donut hole’ are not tied to each other, and there is no need to link the two,” Daniel said. “This is not an either/or scenario. We can achieve both.”

As for the short-term future, “we are hopeful that the changes to the Part D ‘donut hole’ are not reversed,” Daniel said. “Any change would need to be made prior to Jan. 1, 2019, and that window is rapidly closing.”

“We will review any end-of-the- year budget agreements and keep our eye out for any changes that might be included that are related to the Part D donut hole,” she said.

Back to the December 21, 2018 issue of ACP Advocate