The Medicaid VBPs for Patients Act would clarify value-based contract pricing in Medicaid that aligns with Medicaid’s best price rule, and the new cell and gene therapy access model allows CMS to negotiate a contract based on the value for expensive cell and gene therapies in his name. states, which should expand patient access to these therapies, said Adam Colborn, JD, associate vice president of Congressional Affairs, AMCP.

This transcript is lightly edited for clarity.

Transcription

What are some of the value-based care programs being tested in Medicaid and how do they differ from Medicare programs?

I will say a lot of our focus is on the Medicaid side. When it comes to Medicare, we’re seeing much more frequent use of fee-for-service services, especially under traditional Medicare. We’re kind of hoping that the things that we’re focusing on in Medicaid can also help speed things up in Medicare.

At AMCP, we’ve really focused on the Medicaid side of things. We are big supporters of a bill, the Medicaid VBPs for Patients (MVP) Act (VBP stands for value-based purchasing agreement), introduced in the House and Senate. What this bill would do is codify Medicaid’s “best multiple price” rule, which allows manufacturers to report a fee-for-service price and value-based outcomes, a value-based contract price for purposes of the Medicaid best price rule. Most people watching probably know that Medicaid qualifies for the lowest price in the country, but the question that arose when value-based contracts began to appear was: What if Medicaid fails? a drug – and the payer ends up paying $0 or gets a 100% discount on the cost of the drug – does this then set the price at $0 for every Medicaid program in the country? So Medicaid’s multiple best price rule was intended to address this problem. But I think we have seen that there are some points that need clarification.

The MVP Act, in addition to codifying the best multiple price rule, would also define certain important terms that are not defined in current regulations or defined elsewhere in statutory law. It defines a drug’s average manufacturer price and average sales price, both of which are very important in calculating your best price under Medicaid’s best price rule. Next, value-based arrangements would also be excluded from the anti-kickback statute. So operating under this program would not conflict with that. And that’s something we pay a lot of attention to.

Also on the Medicaid front, there is a model at the (Center for Medicare and Medicaid Innovation) that was recently announced (I don’t believe anyone has launched it yet), but it is the Access to Medicaid model. cell and gene therapy (CGT), the cell and gene therapy (CGT) access model. CGT access model. This is essentially a multi-state contracting approach. This model would allow CMS to negotiate a value-based contract for these expensive cell and gene therapies, and states would then have the option to sign this contract negotiated on their behalf by CMS, regardless of the therapy. Maybe it’s gene therapy for sickle cell disease. CMS would go and negotiate all the terms, and it would be a standard contract that Medicaid would then be entitled to. This was just announced in September or the end of August, and it’s something that we’re monitoring as well, especially since…we want to make sure that these patients have access to the very expensive medications.

Given the population covered by Medicaid, how important is it to implement value-based agreements to expand access to care?

One of the main reasons we support the MVP Act is that Medicaid patients are not well equipped to access these treatments outside of the Medicaid program. These are often the most vulnerable patients in our communities, and some of the other options available to people with commercial insurance may not be available to them.

And Medicaid programs, as we know, often operate on fairly tight budgets. They don’t have much room to maneuver. Even though it is a large budget, it is really just to cover the expenses they have and they are not able to absorb the cost of a treatment that does not work, especially when it comes to cell and gene therapies. where the cost is hundreds of thousands or millions of dollars.

In reality, for us, it’s a question of fairness. We want to see these policies – the CGT Access Model and the MVP Act – succeed so that Medicaid programs have the tools they need to facilitate access for their beneficiaries.