The smart money has for some time questioned the willingness of Medicare to indefinitely sustain a drug reimbursement policy founded on parallel universes. One universe, known more conventionally as Part B, deploys Average Sales Price and competitive acquisition methodologies to pay for those drugs traditionally thought of as being within the program's 
"medical" sphere -- i.e., stuff injected by physicians in their offices, dispensed via DME, etc. But come January 1 the other universe -- to be known as Part D -- kicks in. It's the true "pharma" sphere because it's generally about transferrring to consumers little pharmacological articles called pills that don't usually require the laying on of expert medical hands.
CMS has issued a draft guidance that's complex enough to itself suggest futility in finding any enduring set of principles for divining the Part B-D payment frontier. Now similar vibes are starting to seep out of the private sector as it looks for the most cost-effective way to manage drug costs.
As the recent annual meeting of the Pharmaceutical Care Management Association, for example, there was talk about how difficult it is to pierce the veil of medical benefits to get at true costs of the drugs bundled inside. In contrast, so the argument went, the pharmacy benefit stands out by itself, alone and naked, which helps put costs in sharper relief. Thus, by moving drug services -- especially specialty drug services -- from the broader and fuzzier medical bundle into the more revealing pharmacy offering, managers can understand, in a comprehensible and comprehensive way, what they're dealing with. Such is said to be aided by the fact that clearly delineated services can more readily be lit up electronically to produce minable data. Erasing the medical/pharma distinction is also touted as helping rationalize separate and unequal cost-sharing requirements that today allow patients invested in both benefits to play co-pay arbitrage.
In the Handwriting on the Wall Dept., then, look for an eventual Medicare merging of universes that will render the Part B v. D drug distinction a quaint reminder of the way things used to be.
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