回扣模式将如何影响医疗保险D部分中价格协商药物的现金流？

How will a Rebate Model ImpactCash Flow for Price NegotiatedDrugs in Medicare Part D? SHANYUE ZENG, MA,IQVIA Market Access Technology SolutionsCHUAN SUN, MS, MA,IQVIA Market Access Technology SolutionsWILLIAM SARRAILLE, JD,University of Maryland Francis King Carey School of LawRORY MARTIN, PHD,IQVIA Market Access Technology Solutions Table of contents Abstract1Introduction2MFP rebate model3Previous studies4Study aims4Data and Methods5Data5Payment timing5Financing assumptions5Inventory management6Model6Limitations6Findings7Sensitivity analysis9Discussion11Conclusion11References12AppendixA:14AppendixB:14About the authors15Acknowledgements15Funding15Conflictsof15 Abstract Based on our findings, an MFP refund decreasespharmacy interest costs slightly versus the pre-MFPbaseline — from 0.47% to 0.40% of WAC — becausethe timing of payments by pharmacies to wholesalersfor the drugs they purchase is largely offset bymanufacturer refunds and payer reimbursements thattogether effectuate MFP, minimizing liquidity gaps. Forthe 10 negotiated drugs, estimated interest costs fallfrom $274 million to $239 million on an expected totalpre-MFP reimbursement of $145 billion, using 2023utilization of the MFP drugs. In contrast, interest costsfor the proposed 340B rebate model at entity-ownedpharmacies were less than half those of the MFP refundmodel. This is mainly due to fewer process steps and theshorter timelines mandated by the Health Resources andServices Administration (HRSA) in connection with those340B rebate payments. In January 2026, the Centers for Medicare & MedicaidServices (CMS) will implement a key provision of theInflation Reduction Act — reimbursing negotiateddrugs at the maximum fair price (MFP). CMS is expectedto operationalize MFP using manufacturer refunds(rebates) paid to pharmacies after the drug is dispensed,a mechanism critics contend will introduce delaysbetween drug purchase, payer reimbursement, andrebate payment — potentially impacting pharmacy cashflow. Supporters of the refund model argue that theseconcerns are overstated. This study estimates the financial impact of an MFPrefund model on pharmacy cash flow and interest costs.We also compare these effects to those of the recentlyannounced rebate model pilot for the 340B DrugPricing Program (“340B program”), since both modelsinvolve delayed manufacturer payments that may affectpharmacy liquidity. These findings suggest that the condition imposed byHRSA to demonstrate 340B rebate performance beforeexpanding beyond the initial 10 drugs of the rebate pilotmay warrant reevaluation, given CMS’s acceptance of arebate model for MFP drugs that involves higher costs. We developed data-driven models expressing interestcosts as a percentage of the wholesale acquisition cost(WAC) of the drug, and applied them to 2023 MedicarePart D gross costs for the 10 drugs selected for Medicareprice negotiation in 2026. Pharmacies are typically reimbursed by Part D andcommercial payers for branded drugs at a discountoff the average wholesale price (“AWP minus”) plusa dispensing fee.5Because AWP minus is above theiracquisition cost, which is around WAC, pharmaciesgenerate revenue from the spread. Introduction The Inflation Reduction Act of 2022 fundamentallychanges Medicare drug pricing by granting CMSthe authority to negotiate prices for select high-expenditure drugs. Beginning January 1, 2026, the first10 drugs selected for Medicare Part D price negotiationwill be reimbursed at maximum fair price (MFP) andan MFP refund will be paid by the manufacturer, asrequired by the Inflation Reduction Act for Part Dpatients.1Price negotiation will be implemented inphases: 10 Part D drugs in 2026, 15 Part D drugs in2027, 15 Part B and D drugs in 2028, and 20 drugs peryear thereafter.2CMS estimated 2023 Part D grossexpenditure for the first 10 drugs was $56.2 billiondispensed to nearly 10 million beneficiaries.3 This reimbursement system is significantly altered underMFP. Medicare negotiated drugs will be reimbursed atMFP with the manufacturer paying a rebate equal toWAC minus MFP,5which will force margins close to zerofor MFP drugs prescribed to Part D patients.6 CMS created two pathways to effectuate MFP: anupfront discount model, and a retrospective rebatemodel. The latter, which most manufacturers prefer,7provides a greater opportunity to determine if a 340Bduplicate discount is present on an MFP drug. This isbecause in a rebate model, the manufacturer has anopportunity to review data related to Part D utilizationbefore paying the rebate. In contrast, under thediscount model, the manufacturer pays the pharmacywithout receiving any data, and, therefore, withouthaving any basis to assess whether a 340B discount hasbeen provided on the same drugs. The same 10 drugs have also been chosen by HRSAfor a rebate pilot for the 340B program, increasing thecomplexity and impact of these changes. The 340Brebate pilot is designed to enable manufacturers to avoidproviding duplicate