AMGA: Pharmacy Claims Data Key to Value-Based Care Progress

Lawmakers have their eyes on pharmacy benefit manager (PBM) reform, but one bill is looking to take it a step further by requiring commercial payers to share pharmacy claims data with providers to progress value-based care.

Senator Markwayne Mullin (R-OK) recently offered an amendment to S. 1339, the Pharmacy Benefit Manager Reform Act, which was first introduced by Senators Bernard Sanders (I-VT) and Bill Cassidy (R-LA), the Chair and the Ranking Member of the Senate Health, Education, Labor, and Pensions Committee, late last month. The bill aims to expand oversight and enforcement of PBMs by ensuring PBMs remit all of the rebates, fees, alternative discounts, and other remuneration received from drugmakers and the kind for utilization of prescription drugs under health plan coverage rules.

The American Medical Group Association (AMGA) said the amendment requiring commercial payers to share data with payers is a major move for value-based care.

"Allowing providers to access administrative claims data from commercial payers has been a longstanding priority for AMGA and its members," AMGA President and CEO Jerry Penso, MD, MBA, said in a statement yesterday. "The passage of this amendment will ensure that multispecialty medical groups and integrated delivery systems have access to this data, which provides a more comprehensive view of their patient's health, which is key to providing better care."

Lack of access to administrative claims data is a major barrier to value-based care progress, according to risk-readiness surveys conducted by AMGA annually for the past five years. Specifically, providers have cited lack of access to timely claims data as the most significant obstacle to assuming risk and transitioning to value-based arrangements.

“Members report that while some payers share this data with providers, the majority do not. Successfully managing a patient population requires that providers have access to the data to ensure the most effective course of action in improving health outcomes. Without this data, it is challenging to manage the cost and quality of a population of patients, which is a goal of moving to value-based care,” AMGA said in a letter to Senator Mullin.

The amendment would give providers and integrated delivery systems what they need to better care for patients, the association continued.

"This amendment will help providers care for their patients,” Penso added. “We urge Congress to ensure that this provision is signed into law."

The Pharmacy Benefit Manager Reform Act is one of four bills brought forth by Senators Sanders and Cassidy to address challenges in the pharmaceutical industry. The other bills include the Ensuring Timeline Access to Generics Act (S. 1067), Expanding Access to Low-Cost Generics Act (S. 1114), and the RARE Act (S. 1214).

The Pharmaceutical Care Management Association (PCMA) has criticized the Pharmacy Benefit Manager Reform Act, contending lawmakers did not allow for “common sense amendments” which would increase prescription drug costs, if passed.