Download Academy and 100 Other Groups Call on CMS to Immediately

Academy and 100 Other Groups Call on CMS to Immediately Withdraw Demo
Retina specialists would be highly impacted by CMS’ announced initiative
The Centers for Medicare & Medicaid Services announced today that it intends to perform a
Medicare Part B drug demonstration to investigate the impact alternative payment strategies
would have on providers’ prescribing patterns.
In ophthalmology, this primarily impacts retina specialists, along with those who do intravitreal
injections.
The Academy and more than 100 other groups, in anticipation of this announcement, last week
called on CMS to withdraw the proposal and seek broader stakeholder input.
This demonstration would adversely affect the care and treatment of patients with complex
conditions, such as age-related macular degeneration. It would disrupt current treatments or
possibly limit a patient’s ability to find the right treatment for their condition.
The Academy, along with more than 100 healthcare organizations, is calling on the Centers for
Medicare & Medicaid Services to drop its announced outpatient drug-payment demonstration
proposal. The agency released notice of its intent to do the demonstration today, which would
target higher-priced drugs, such as provider-administered biologics.
This would have a significant impact on those in the Academy’s community of retina specialists.
The demo is expected to be implemented in Fall 2016, with a larger phase-in by 2017. Read the
rule.
What is CMS proposing?
CMS is considering two phases of demos aimed at decreasing Part B drug costs. The first phase
focuses on adjusting the add-on to the average sales price to something other than the current 6
percent that providers are paid to administer drugs. As proposed, CMS would pay this average
sales price, plus 2.5 percent. In addition, there would be a flat $16.80 administrative fee.
The control group would continue to be paid the current average sales price, plus 6 percent.
CMS is also developing methods to test the impact of targeted pricing changes to payments for
individual Part B drugs. It would do this using a value-based purchasing strategy and decision
support tools, such as eliminating patient cost sharing. These would be similar to those employed
by commercial health plans, pharmacy benefit managers, hospitals, and other entities that
manage health benefits and drug utilization.
The second phase would be implemented at a later date in conjunction with the first phase.
Why is CMS proposing this?
Many policy makers believe that the existing Average Sales Price-plus-6-percent approach
encourages providers to use expensive products, regardless of effectiveness. CMS wants to test
ways to remove a physician’s incentive to prescribe expensive drugs. In particular, it wants to
test whether changes to the compensation system would remove the lure of greater pay for
prescribing more-expensive drugs.
How long would this demo last?
It would last five years.
What is the Academy doing?
CMS has opened a public comment period, which ends May 9. We will weigh in. We are uniting
with a coalition of other impacted physician and provider organizations, patient groups and
industry partners to oppose this initiative.
Why is the Academy and our partners opposed to this demonstration?
We believe these types of initiatives should be first implemented in a targeted, patient-center,
transparent way. The process should account for the unique needs of Medicare beneficiaries.
The type of initiative CMS is proposing could hurt the care of Medicare patients with complex
conditions, such as macular degeneration, cancer, hypertension, rheumatoid arthritis and primary
immunodeficiency diseases. These are the types of patients that use drugs administered by
physicians, which the Part B drug-pay demo would affect.
These patients often try multiple treatments before finding the right one for their conditions. We
believe that these patients need quick access to the right medications, which is already
complicated by treatment decisions and regulatory issues that may change frequently.
Finally, vulnerable Medicare patients should not face mandatory participation in an initiative that
may force them to switch from the most appropriate treatment.
If you have any questions, e-mail Academy Advocacy Communications Manager Matt Daigle at
[email protected].