Framework Focus

Framework Focus

By A SoftWriters PodcastMedicineHealth & Fitness
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Framework Focus episodes

  • Maximum Fair Price, the IRA, and What DC Means for 2026 and Beyond | Framework Focus
    In this episode of Framework Focus, Dr. Dae Lee breaks down the regulatory and reimbursement shifts reshaping long-term care (LTC) pharmacy. With the Inflation Reduction Act (IRA) moving from policy theory to operational reality, Medicare’s Maximum Fair Price (MFP) program, Part D redesign, and inflation rebate enforcement are now active forces that LTC operators must navigate.

    This conversation moves beyond headlines and into real-world implications: cash flow risk, administrative burden, contracting exposure, and strategic readiness for closed-door and combo LTC pharmacies.

    Key Discussion Points

    1. Medicare Drug Price Negotiation Is Now Operational
      2.  The IRA authorizes Medicare to negotiate prices for certain high-spend Part D drugs, with the first 10 Maximum Fair Prices (MFPs) effective January 1, 2026. This marks a structural shift in federal drug pricing and directly impacts LTC dispensing economics.

    2. Maximum Fair Price and LTC Reimbursement Compression
      3.  MFP caps reimbursement on selected drugs, creating potential margin compression if acquisition costs and payment timing are misaligned. For LTC pharmacies operating on tight spreads and high-volume chronic utilization, even small deltas can materially affect profitability.

    3. Medicare Transaction Facilitator (MTF) and Payment Timing Risk
      4.  The MTF system introduces new payment mechanics between manufacturers, plans, and pharmacies. LTC pharmacies must understand how effectuation and reconciliation work, particularly if payment timing differs from traditional Part D adjudication flows. Cash flow modeling becomes essential.

    4. Administrative Complexity and Claims Reconciliation
      5.  Identifying which NDCs are subject to MFP, managing claim reversals, handling price disputes, and monitoring plan-level compliance will increase administrative workload. LTC pharmacies will need structured internal workflows to prevent reimbursement leakage.

    5. Dispensing Fees and the LTC Service Intensity Problem
      6.  Unlike retail, LTC pharmacy includes compliance packaging, emergency kits, cycle fills, consultant pharmacist oversight, and regulatory documentation. Current IRA implementation does not automatically adjust dispensing or supply fees to reflect this complexity, raising sustainability concerns.

    6. Congressional Efforts to Stabilize LTC Pharmacy
      7.  Legislative proposals such as the Preserving Patient Access to LTC Pharmacies Act aim to create supply fee protections tied to MFP drugs. The episode explores whether policy corrections are likely — and how quickly DC can realistically respond.

    7. Expansion of Negotiated Drug Lists
      8.  The initial 10 negotiated drugs are only the beginning. Additional rounds of negotiation are underway, expanding exposure across more therapeutic classes. LTC pharmacies must treat MFP as a growing structural feature — not a limited pilot.

    8. Part D Redesign and the $2,100 Out-of-Pocket Cap
      9.  Beginning in 2026, the redesigned Part D benefit changes liability distribution among plans, manufacturers, and CMS. The new out-of-pocket cap alters plan incentives and may lead to tighter utilization management, formulary shifts, and network recalibration — all of which LTC pharmacies must monitor closely.

    9. Inflation Rebates and Market Distortion
      10.  The IRA’s inflation rebate provisions penalize manufacturers for price increases above inflation benchmarks. While not directly adjudicated at the pharmacy counter, these provisions influence manufacturer pricing strategy, launch pricing behavior, and downstream PBM negotiations — indirectly affecting LTC acquisition costs.

    10. Strategic Readiness as a Competitive Advantage
      11.  The episode concludes with practical recommendations:
       • Conduct an MFP exposure audit across top-dispensed NDCs
       • Reassess PBM contracts and network participation clauses
       • Model cash flow under delayed reimbursement scenarios
       • Educate facility partners on regulatory changes
       • Build internal compliance tracking specific to negotiated drugs

      Why This Matters Now
      For LTC pharmacies, this is not simply a policy conversation — it is a structural shift in reimbursement architecture. As federal oversight expands and pricing authority evolves, operational precision and legal literacy will define which organizations adapt successfully.

      About our guest: 
      Dr. Dae Lee, Pharm.D, Esq., CPBS 
      Shareholder - Buchanan Ingersoll & Rooney PC 

      Dae Y. Lee is a pharmacist-attorney and Certified Pharmacy Benefits Specialist™ (CPBS™) who represents pharmacies, healthcare stakeholders, and plan sponsors in high-stakes disputes and regulatory matters involving Pharmacy Benefit Managers (PBMs) and government payors. Drawing on his dual training as a pharmacist and attorney, Dae focuses his practice on defending clients in audits, investigations, enforcement actions and complex reimbursement and compliance matters.

      Dae routinely represents pharmacies nationwide in PBM and payor audits, including Fraud, Waste and Abuse (FWA) investigations, extrapolation disputes, overpayment recoupments, credentialing denials, network suspensions and terminations. He advises pharmacies on compliance with applicable state pharmacy fair audit laws, PBM provider manuals, and reimbursement standards, with the goal of minimizing financial exposure while preserving network participation and business continuity.
       
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      23 min
    11. Cybersecurity in LTC: Today’s Threat Landscape & Practical Defense | FrameworkFocus™

      Cyber threats facing long-term care pharmacies continue to evolve, putting sensitive data, systems, and patient trust at risk. In this episode of FrameworkFocus, host Todd Eury sits down with Scott Beatty, President & CEO of SoftWriters, and Chris Callahan of Echelon Risk + Cyber to explore today’s threat landscape and practical strategies to strengthen cybersecurity maturity. From leadership accountability to real-world defense tactics, discover how pharmacies can improve security hygiene and build resilience without slowing innovation.

       

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      49 min
    12. How AI is Transforming LTC Pharmacy | FrameworkFocus™

      In this episode of FrameworkFocus, we explore how artificial intelligence is reshaping long-term care pharmacy. Rick Pollick and Kyle Nilson from SoftWriters’ Alpha Labs join us to discuss the industry-wide impact of AI, the benefits and challenges it presents, and how SoftWriters is bringing innovative, AI-driven workflows to life—starting with AI Order Entry Automation.

       

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      41 min
    13. Turning Information into Impact in LTC Pharmacy | FrameworkFocus™
      In this episode, host Todd Eury sits down with Terry Dean and Amanda Malooley to explore the growing importance of business intelligence in long-term care pharmacy. Together, they discuss the challenges pharmacies face in accessing and interpreting data, why real-time insight is becoming mission-critical, and how smarter visibility leads to better operational and clinical outcomes. The conversation then traces the journey behind FrameworkInsight—how it was envisioned, built, and continues to evolve to support pharmacy leaders in making informed, confident decisions.
      54 min
    14. Live from the FrameworkLTC Innovation Conference (Part 3) | FrameworkFocus™

      In the final installment of our three-part series, host Todd Eury wraps up his live coverage from the 2025 FrameworkLTC Innovation Conference. Tune in for more engaging interviews with LTC pharmacy attendees, partner exhibitors, and SoftWriters team members as they reflect on the event’s biggest moments and discuss what’s ahead for the LTC pharmacy community.

      42 min
    16. Live from the FrameworkLTC Innovation Conference (Part 1) | FrameworkFocus™

      In part one of our special three-part series, join host Todd Eury as he takes you inside the 2025 FrameworkLTC Innovation Conference. Recorded live on-site, this episode features conversations with long-term care (LTC) pharmacy leaders, partner exhibitors, and members of the SoftWriters team. Hear firsthand insights and success stories that highlight innovation, collaboration, and the future of LTC pharmacy.

      33 min
    17. From Constraint to Catalyst: Interest Rates and the LTC Market | Framework Focus

      In this episode of FrameworkFocus, we explore how the long-term care (LTC) market has evolved from the pre-pandemic boom through COVID-19’s sharp disruption to today’s near-recovery. Jason Yablinsky, CFO at SoftWriters, unpacks how shifting interest rates, housing liquidity, and the coming wave of Baby Boomer demand are reshaping the industry’s trajectory. Tune in to learn why today’s financial constraints may soon become tomorrow’s catalysts for growth.

      32 min
    18. Where LTC Pharmacy Connects: Preview of the 15th Annual FrameworkLTC Innovation Conference | Framework Focus

      In this special episode of FrameworkFocus, we’re getting you ready for the 2025 FrameworkLTC Innovation Conference—Where LTC Pharmacy Connects. You might remember it as our “User Conference,” but we’ve refreshed the name to better reflect where we’re headed. This event has always been about more than just software; it’s about accelerating innovation, sharing ideas, and shaping the future of Long-Term Care Pharmacy. Tune in as we highlight what’s new for this year, what attendees can expect, and why this event continues to be a must-attend gathering. Plus, hear from Matthew Gilbert, VP of Business Transformation and Major Accounts at RxSafe, Diamond sponsor this year, who shares insights from a vendor perspective and discusses why RxSafe is excited to participate in this year’s conference.

      1 hr 10 min
    19. Mapping the Customer Journey | FrameworkFocus™

      In this episode of FrameworkFocus, VP of Customer Success Jackie Maitland is joined by Eric Fernandez and Dustin Harbison to explore the full customer journey at SoftWriters—from first engagement through implementation, account management, and long-term growth. Together, they share how collaboration, transparency, and continuous feedback shape a partnership built for lasting success in the long-term care pharmacy space.

      31 min

    About Framework Focus

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    You’re listening to ”Framework Focus,” the podcast that explores trends, innovations, and insights in the long-term care pharmacy industry. Join us as we connect the entire LTC ecosystem.