The House of Representatives Energy and Commerce Committee ("the Committee") circulated draft language to include in its 21st Century Cures legislation earlier this week to reform the 340B drug discount program (the "340B Program"). Although the draft 340B language was pulled from the legislation yesterday, the language proposed provides insight into what future legislative reform may include. The draft language, if adopted, would have a substantial impact on all 340B Program stakeholders, including, covered entities, contract pharmacies, 340B technology vendors, and drug manufacturers.
The draft language addressed the concerns of several Committee members during the Health Subcommittee hearing on March 24, 2015 (discussed here), including the lack of clarity surrounding the patient eligibility definition, the lack of transparency on how hospital-based covered entities use 340B savings to benefit underserved patients, and the Health Resources and Services Administration's ("HRSA") limited authority to issue regulations and enforce 340B Program requirements. In addition, the draft language would impose several new requirements on 340B contract pharmacy arrangements. The following summarizes several key provisions included in the draft language.
Patient Eligibility Definition
The proposed language defining "patient" did not significantly deviate from the existing definition set forth in HRSA's 1996 guidance, but added a requirement that the patient have an "in-person" clinical or medical visit at the covered entity.
New Obligations for Covered Entities
The draft language proposed several new requirements of covered entities in order to participate in the 340B Program, including the following:
- Covered entities would pay a user fee not to exceed 0.1 percent of covered outpatient drug purchases.
- Covered entities with high volume purchases would be required to conduct an annual independent audit of the entities' 340B Program compliance, and provide the results to the Department of Health and Human Services ("HHS").
- Hospital-based covered entities (except for critical access hospitals) would be subject to substantial new reporting requirements, including the submission of an annual report detailing the following: (1) patient breakdown by payor and the aggregated amount of acquisition cost and reimbursement for covered outpatient drugs by payor, (2) the use of its 340B Program revenue relating to the access and provision of health care for the uninsured, underinsured, underserved and medically vulnerable, (3) its prevention of duplicate discounts, (4) the number of covered outpatient drugs dispensed by each of its contract pharmacies, (5) the amount of uncompensated care, and (6) the name of any third parties or vendors that administer its inventory management system or contract pharmacy arrangement.
Guidance on Contract Pharmacies
The proposed language also addressed contract pharmacies and imposed some potentially onerous obligations for covered entities and contract pharmacies. The contract pharmacy language required covered entities utilizing contract pharmacies to:
- Have a contractual agreement in place with each contract pharmacy;
- Register the contract pharmacy agreement and the contract pharmacy's "distance" from the covered entity with HRSA;
- Ensure compliance of each contract pharmacy agreement with the requirements to prevent drug diversion and duplicate discounts;
- Develop a mechanism to track the income of the patients of the covered entity and the amount such patients pay to receive covered outpatient drugs from the contract pharmacy;
- Maintain and ensure that each contract pharmacy maintains, auditable records;
- Develop a process and conduct review of prescribing and dispensing records to identify irregularities; and
- Provide annual audits of the contract pharmacy to be conducted by an independent auditor.
Expanded HHS Authority
The proposed changes would have provided HHS with the authority to establish limits on what the uninsured pay for 340B drugs and allowed HHS to impose new penalties on covered entities for non-compliance with the 340B Program. Perhaps, most significantly, the proposed language would have given HHS the authority to issue regulations addressing several areas of the 340B Program including, but not limited to, covered entity eligibility, patient definition, contract pharmacy arrangements, covered entity reporting requirements, duplicate discounts, limits on amounts charged to uninsured patients, and penalties for non-compliance.
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