340B Insight

The ancillary outpatient sites known as 340B child sites serve as important places for patients to access the drugs and care they need. There are crucial steps involved in effectively onboarding potential child sites as well as ongoing processes involved with maintaining the parent hospital’s partnership with those sites. University Hospitals Cleveland Medical Center  340B Pharmacy Manager Joe Moss joins us to shed light on this process and the potential problems to be on the lookout for.

How is a 340B child site onboarded?

Moss says the first big step to identifying potential sites is to work with a hospital’s finance, revenue, pharmacy, and legal departments to evaluate a site. The team looks at Medicare cost reports and trial balances to ensure they are eligible for 340B. As part of the process, they also use electronic medical record and retail data to identify potential clinic areas based on their patient volumes.

A 340B child site is registered. Now what?

The work is not over once a child site has been registered in 340B. UH has a program it calls the “340B Concierge Program,” which aims to provide comprehensive, ongoing support and guidance to a given child site. The program offers additional education and information in such areas as procurement processes, the appropriate ways to handle drug transfers, and miscellaneous licensing issues.

Onboarding requires relationships and a close eye on compliance

Moss says that hospitals onboarding a child site should establish and maintain close ties with the site to prevent issues with 340B compliance. This can involve being the first line for any pharmacy issues the site staff might be having, holding frank conversations with clinic management when necessary, and inviting staff to observe mock audits so they can learn more about what goes into maintaining 340B compliance.

Resources:

1. Trump Executive Order Could Revive Medicare 340B Cuts

Health Resources & Services Administration (HRSA) audits of hospitals play a key role in ensuring compliance with 340B rules and regulations. In this episode, Dave Lacknauth, executive director of pharmacy services at Broward Health in Fort. Lauderdale, Fla., joins us to discuss the importance of taking a proactive, comprehensive approach to audit readiness with the goal of ensuring clean audit results. 

Compliance protects 340B access

Being prepared for HRSA audits serves a crucial function that ultimately benefits the patients whom hospitals serve, Lacknauth explains. Maintaining the integrity of 340B means protecting access to 340B savings that hospitals can invest in crucial care for community members that need it. 

Continuous audit readiness

Lacknauth discusses how Broward Health maintains audit readiness by conducting internal audits, bringing in external consultants, and identifying areas of opportunity for improvement. A robust system of internal reviews means that when HRSA comes knocking, Broward Health is already prepared. This was evident after a recent audit of one of the system’s hospitals that resulted in zero recommendations for improvement.

Organization, resources, transparency are key

Preparing for audits requires a health system to invest time and resources, but Lacknauth stresses that these investments pay off. Engaging a comprehensive team from various departments in the audit readiness process allows for a health system to have the appropriate level of responsiveness and transparency during a HRSA audit.

Resources:

1. Nebraska Is 12th State To Enact Contract Pharmacy Protections
2. Idaho Becomes Fourth State To Mandate 340B Reports From Hospitals

Artificial intelligence continues to impact industries, including pharmacy and 340B. As hospitals and health systems consider adopting AI, we spoke with Kristin Chupka, the 340B program system director for Dartmouth Health, who shares her experience launching this initiative there and considerations for entities seeking to do the same.  

AI, automation, and how they can support 340B

Chupka distinguishes that AI is like a machine learning and making decisions depending on what it is taught. Automation, although similar to AI, does not make decisions. Both can systematize processes and with the help of guardrails, enable pharmacists to dedicate more time to patient care. 

Opportunities and considerations 

The novelty of AI promises an opportunity for 340B teams that can consider and correct its potential pitfalls. Chupka explains that as with any emerging technology, it is best to start slowly, teach the algorithm, and consistently check in to ensure accuracy and ethical considerations. This approach can limit errors and inspire confidence as time goes on. 

What entities can learn from Dartmouth Health? 

The Dartmouth Health team has explored how AI can help with budgeting, modeling, and auditing, always double-checking work to avoid errors. Because a fully staffed team is required for this, Chupka reassures that AI has not affected staffing. If anything, Chupka says AI is a tool to assist in compliance. 

Check out all of our episodes on the 340B Insight podcast website. You also can stay updated on all 340B Health news and information by visiting our homepage. If you have any questions you’d like us to cover in this podcast, email us at [email protected]. 

Resources:

1. 340B Health, Member Hospitals Ask Court To Throw Out Drugmaker Rebate Lawsuits)

Hospital clinical pharmacies play a key role in ensuring patients are taking medications effectively and supporting other providers who are managing their care. Mark Riggle, the assistant chief pharmacy officer at UC Davis Health, explains how 340B helps make this direct care and ancillary support possible.

Clinical pharmacies are a bridge between providers and patients

Riggle says clinical pharmacy teams serve as drug experts that can help teach patients about potential side effects and how to take their medications properly. But these teams also can take the lead on supporting other providers on refills, prior authorizations, financial assistance, and more. That allows the other providers to focus less on those processes and more on providing medical care to the patients. 

In-house pharmacies can improve patient care and generate revenue

Using an in-house clinical pharmacy has benefits for both patients and the hospital. Riggle notes that keeping prescriptions and pharmacy support in-house can enable hospitals to keep better track of patients’ health and identify if there are issues or questions with certain medications. At the same time, it generates revenue and 340B savings that support even more hospital services and improve patient health outcomes even more.

Ramping up clinical pharmacy services and overcoming barriers can take time

Riggle says expanding clinical pharmacy initiatives at UC Davis Health has come with some challenges. It took years to roll out a refill program for all the providers who needed that support, and achieving success with a prior authorization program involved an evaluation of workflows to improve efficiency. But he noted that hospital pharmacists can present a value proposition to their leaders for how investing in 340B-supported clinical pharmacy services can be worth it to improve care quality and provider satisfaction.

Resources

1. Federal Judge Allows 340B Health, Member Hospitals To Intervene in Rebate Lawsuits

The legal fight over drugmakers’ push to impose 340B rebates is heating up, with five lawsuits pending in a federal court in Washington, D.C. Recently, 340B Health joined with two of its member hospitals in asking the court to intervene as defendants to stop these rebates from taking effect. Genesis HealthCare System based in Ohio is one of those hospitals. Shona Carr, the director of 340B and ambulatory pharmacies at Genesis, breaks down how rebate models would create financial challenges for hospitals that would hamper their patient care initiatives.

Carrying and Compliance Costs

Each drugmaker’s push to impose rebates would incur new drug purchasing and compliance expenses for covered entities. Bristol-Myers Squibb’s rebate policy alone would cost Genesis HealthCare System an additional $400,000 per month in drug spend if it applied to all BMS drugs. If 340B rebate models became the norm for all drugmakers, Carr estimates Genesis would pay an additional $5.2 million per month in upfront costs. Those figures do not include additional hundreds of thousands of dollars in annual staffing expenses to process rebate claims and challenge denials.

Effects on Patient Care and Support

Imposing 340B rebates could force Genesis HealthCare System to scale back or discontinue its patient assistance program, according to Carr. But 340B savings do not just go towards direct patient help with drug costs at the hospital. The financial impact of rebates also could affect other community programs and free services, such as patient transportation, meds-to-beds, health screenings, and a paramedicine program.

Advice for Other Hospitals

Carr says every covered entity that has not already done so should begin reviewing drugmaker rebate policies and working with their 340B third-party administrators to estimate potential costs. She says this involves entities asking bigger questions: Would rebate policies require additional 340B staffing? Does senior leadership understand the potential impact of these changes? What 340B-funded programs might be at risk?

Resources:

1. 340B Health Seeks To Intervene in All Drugmaker Rebate Lawsuits
2. Declaration of Shona Carr in Support of Motion To Intervene

In what has become an annual tradition for the podcast, we consulted with 340B Health’s expert staff to answer our listeners’ most pressing 340B questions. As an uncertain and busy year starts for the world of 340B, we want to prepare you by covering your queries about the efforts by drug companies to impose 340B rebates, proposed federal and state legislation on 340B, how Inflation Reduction Act implementation will affect 340B, and more.

340B Rebate Lawsuits Heat Up

So far, five drug companies have sued the Health Resources & Services Administration to challenge HRSA’s rejections of their backend rebate proposals. 340B Health Vice President of Legal and Policy Amanda Nagrotsky notes that a rebate model would harm 340B hospitals through delayed access to 340B savings and potentially denials of legitimate rebate claims based on drugmaker interpretations of 340B rules. We recorded this episode just before 340B Health filed a motion to intervene as a defendant in the Johnson & Johnson (J&J) rebate lawsuit against HRSA.

Lawmakers Eye Ways To Protect or Cut 340B

The new year means a new Congress and the start of new state legislative sessions. 340B Health Senior Vice President of Government Relations Tom O’Donnell notes that members of Congress have floated potential reductions in what the federal government pays for 340B drugs to help fund new spending priorities outside of health care, though it is unclear how seriously they are considering those options. 340B Health Vice President of Legal and Policy Greg Doggett reports that several states are considering new contract pharmacy or payment nondiscrimination protections for 340B hospitals, but others have introduced proposed new mandates for covered entities. 

Price Caps Will Apply to More Medicare Drugs

The list of drugs eligible for Medicare price caps will grow to 25 starting in 2027 under the Inflation Reduction Act, which will have implications for 340B savings on those drugs. 340B Health Research and Policy Analytics Manager Claudia Escue notes that popular weight loss and diabetes drugs like Ozempic and Wegovy have made the price cap list because of how much they cost Medicare. 340B Health is tracking how these price caps might lower 340B savings and have submitted letters to Medicare officials to represent other hospital concerns about the implementation of the IRA.

Resources:

1. 340B Health Files Motion To Intervene in J&J Rebate Lawsuit
2. Option To Cut Commercial Pay Rates for 340B Drugs Is on Draft Congressional Budget “Menu”
3. Medicare Expands List of Drugs Subject to Price Caps, Decreased 340B Savings
4. 340B Coalition Winter Conference Registration 

A Minnesota requirement for covered entities to submit data on the costs they pay and the payments they receive for 340B drugs yielded its first annual report this past November. Today’s guest, Minnesota Hospital Association Director of State Government Relations Danny Ackert, tells us why the report’s findings don’t tell the whole story.

The Context for the Dollars 

The first Minnesota report concluded that covered entities received a net of $630 million in payments for 340B drugs in 2023 and paid $120 million to contract pharmacies and third-party administrators. But Ackert notes the figures do not account for what entities would have paid for drugs at non-340B prices, nor what pharmacy administrative costs they would have had if they did not have access to 340B.

Where the Money Goes

Ackert notes that the report does not spell out how hospitals in the state use their 340B savings to stretch resources and provide more care and support to patients. He notes that Minnesota hospitals spend about $15 billion a year providing care. They also face an annual shortfall of about $1.8 billion from Medicare and Medicaid underpayments, a figure that does not even account for charity care, bad debt, and other unreimbursed hospital spending. Some rural hospitals in the state rely on 340B savings just to stay open.

What Other States Can Learn

Although submitting data for the report and countering misconceptions about its findings have been challenging for Minnesota hospitals, Ackert also notes that it has given them an opportunity to educate policymakers about 340B. By learning more about the report and following the state’s example, hospitals in other states considering reporting mandates can put themselves in a position to explain to lawmakers why 340B is so vital.

Resources:

1. Minnesota 340B Covered Entity Report
2. Episode 89: How New 340B Reporting Requirements Are Affecting Hospitals (February 2024)
3. 340B Medicare Hospital Pay Cuts Floated as an Option for Congress

Earlier this year, the Health Resources & Services Administration took a strong stance against drug giant Johnson & Johnson’s plan for a proposed 340B rebate model, but the fight over rebates is far from over. 340B Health President and CEO Maureen Testoni joins us to discuss how the company is taking the issue to federal court and how they are not the only drugmaker doing so.

J&J Sues HRSA Over Rebates

J&J is arguing in court that HRSA lacks the authority to block a 340B rebate model. Such a model would allow individual drug companies effectively to impose their own rules on 340B drug purchases. These rules would curtail the number of drugs a company would offer a 340B discount on and reduce the number of patients that would be deemed 340B-eligible.

Other Drugmakers Pushing Rebates

Bristol Myers Squibb and Eli Lilly also sued HRSA, claiming the agency does not have the authority to stop a rebate model. Sanofi has not yet filed suit but is saying it will impose its rebate scheme in early January. The Sanofi model raises significant concerns not just because of the imminent effective date but because it would impose far more stringent restrictions on 340B eligibility than HRSA ever has.

State Contract Pharmacy Laws Rack Up More Wins

In another 340B issue before the federal courts, state contract pharmacy protections continue obtaining key litigation wins. Several district courts and one appeals court have upheld state laws designed to protect covered entity access to 340B pricing through community and specialty contract pharmacies.

Resources:

1. Brief Your Leadership on Drugmaker Rebate Schemes
2. The Wall Street Journal: “The Economic Imperative of Protecting 340B”
3. Register for the 340B Coalition Winter Conference

What Does the GOP Trifecta Mean for 340B?

In January, Republicans will achieve what’s known as a governing trifecta – taking control of the executive branch combined with GOP majorities in both the U.S. House and Senate. How will this new dynamic affect the 340B world? We discuss what is ahead with McDermott+ vice presidents Rodney Whitlock, a former Republican legislative staffer, and Debbie Curtis, a former Democratic legislative staffer.

Capitol Hill Shakeups and New Faces

Several 340B champions are set to leave Congress through retirement or new appointments, including Reps. Elise Stefanik and Abigail Spanberger as well as Sens. Debbie Stabenow and Ben Cardin. But this provides an opportunity to speak to newly elected lawmakers to express the value of 340B and what it means for their constituents.

Preparing for 340B Oversight

The new Congress could bring oversight hearings and other opportunities for 340B critics to speak out. Although 340B has faced and surmounted challenges before, this will require getting back to core advocacy efforts designed to protect the program.

Trump’s Second Term

How the second Trump administration will fill key roles and the decisions they make on health policy issues could impact 340B. The implementation of Inflation Reduction Act drug pricing provisions also will affect 340B and could lead to discussions about additional changes to the program.

Resources:

1. Create or Update Your 340B Impact Profile
2. Read Our Analysis of J&J’s Legal Arguments for 340B Rebates
3. Lilly, Kalderos Press Federal Court for Ability To Impose Rebates

The focus of attention on cancer care most often goes to the curative treatments required to put cancer into remission, but what do cancer survivors need after that point to fully recover and lead their best possible lives? We discuss that question and how 340B can help answer it with guests Sarah Loschiavo and Ellen Morris-White, two nurse practitioners with UConn Health based in Farmington, Conn.

Survivorship Care at a Crucial Time

UConn Health’s Cancer Survivorship Program is led by advanced practice registered nurses who provide comprehensive care and support to cancer patients starting three to six months after their curative cancer treatments are complete. With the help of 340B funding, the multidisciplinary program is broad in scope, including referrals to meet cancer survivors’ physical, psychosocial, spiritual, and financial needs. The goal is to keep patients on the road to recovery and to continue screening for any cancer recurrence or secondary cancers that could occur.

340B Is Key To Covering Costs 

UConn Health covers the costs of its survivorship care, and low-income patients can receive additional financial assistance for their ongoing cancer therapies through this program. 340B funding is essential to making that happen. Over time, the program is expected to decrease health care costs by avoiding hospital readmissions and cancer recurrences. 

Building Out Best Practices

Evidence on survivorship care models is lacking, but UConn Health has worked on research that could provide some best practices for other institutions. Although there is no one-size-fits-all approach for hospitals, they can use elements of the nurse practitioner-led, interdisciplinary model to meet cancer patients’ needs months and even years after curative treatment. 

Resources: 

1. UConn Health Cancer Survivorship Program
2. Designing, Implementing, and Evaluating an Interprofessional Survivorship Model of Care in an Academic Cancer Center