United States: CMS Proposed Rule Reduces Drug Payments & Requires Implementation Of Value-Based Purchasing Tools

Recently, CMS published a Proposed Rule seeking to test a new model for how Medicare pays for drugs and biologicals paid under the Medicare Part B program. With the goals of determining whether alternative drug payment models will result in "better care" and "smarter spending" by reducing Medicare expenditures while enhancing the quality of care, CMS proposed a two phase Part B Drug Payment Model to "test whether alternative payment approaches for Part B drugs improve value (relative to current drug payment approaches under Part B)."

Current Payment Model

Medicare Part B reimburses physicians for the costs of certain drugs and biologicals that are not usually self-administered but are provided as part of a physician service in a physician office. For hospital outpatient services (paid under Part B), although most drugs are included in a bundled payment, some drugs are paid separately. Certain other categories of drugs are also paid under Medicare Part B (such as oral anti-cancer drugs), but most prescription drugs are covered under Medicare Part D and are not impacted by this Proposed Rule.

Currently, most Part B drugs are paid based on the Average Sales Price (ASP) plus a statutorily mandated 6% add-on. The ASP is defined in Section 1847A of the Social Security Act as a weighted average sales price for all National Drug Codes that are assigned to a Healthcare Common Procedure Coding System code and does not vary based on the price an individual entity paid or the effectiveness of the drug. Payment for these products does not include the professional charge to administer them to patients (such as by injection or infusion).

Based on a 2015 MedPAC Report to Congress, CMS believes that the ASP payment methodology may encourage the use of more expensive drugs because higher priced drugs result in higher add-on payment amounts (because the add-on is a percentage of the ASP, and the ASP varies by drug).

Proposed Rule Phase 1

As proposed, CMS will implement a variation to the add-on component of Part B drug reimbursement. In different geographic regions of the country, the 6% add-on to the ASP used to make Part B drug payments will be reduced to 2.5% plus a flat fee of $16.80 as the alternative add-on amount. The fee would be annually adjusted based on the percentage increase in the consumer price index for medical care for the most recent 12-month period. The proposal requires all providers and suppliers, including physicians, durable medical equipment suppliers, and hospital outpatient departments, furnishing any Part B drugs included in the selected geographic region to participate in the new payment model.

Hinting at where CMS might focus future drug cost containment efforts, CMS notes in the Proposed Rule that the Phase 1 approach addresses the add-on to the drug manufacturer's ASP but not the ASP information actually reported. The preamble to the Proposed Rule notes that "[f]or a given HCPCS code, the add-on represents about 6 percent of an ASP-based Part B drug payment; the remaining 94 percent of the payment is calculated from the manufacturers' reported ASP data," making "ASP . . . a more significant driver of drug expenditures than the add-on payment amount for Part B drugs."  81 Fed. Reg. 13229, 13232 (March 11, 2016).

Proposed Rule Phase 2

In conjunction with Phase 1, as proposed, CMS will implement with Phase 2 so-called "value-based purchasing tools," such as those used by commercial health plans, pharmacy benefits managers, and other private payers to manage drug cost. CMS proposes using one or more tools, such as "indication-based pricing," "reference pricing," and "clinical decision support tools" to Part B drugs, to see if and how much the tools affect expenditures and patient outcomes.

Seeking Comments

Comments in response to the Proposed Rule are due to CMS by May 9, 2016.

In addition to soliciting comments relating to Phase 1 and Phase 2, CMS is seeking comments on:

  • How to create value-based purchasing arrangements with manufacturers under Medicare fee-for-service payment for drugs;
  • Whether CMS should consider implementing an updated version of the Competitive Acquisition Program for Part B Drugs and Biologicals; and
  • Whether CMS should pursue a more bundled or episode-based approach that moves beyond a fee-for-service payment structure.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

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