The Medicaid VBPs for Patients Act would clarify value-based contract pricing in Medicaid, consistent with Medicaid’s best price rule, and the new Cell and Gene Therapy Access Model would allow CMS to negotiate a value-based contract on behalf of expensive cell and gene therapies. It allows. “The number of states that need to expand patient access to these treatments,” said Adam Colborn, JD, AMCP vice president of congressional affairs.

This transcript has been lightly edited for clarity.

Transcript text

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

I will say that most of our focus is actually on the Medicaid side. We’re seeing much greater use of fee-for-service on the Medicare front, particularly in traditional Medicare. We’re kind of hopeful that these things that we’re focusing on in Medicaid can help speed things up in Medicare as well.

At AMCP, our focus was really on the Medicaid side of things. We are big supporters of the Patient Medicaid VBPs (MVP) Act (VBP stands for value-based purchasing regulation) bill that has been introduced in the House and Senate. What this bill will do is codify the Medicaid “multiple best price” rule, which allows manufacturers to report a fee-for-service price and value-based outcomes, value-based contract price, for purposes of the Medicaid best price rule. Most people watching this probably know that Medicaid has the right to charge the lowest price paid anywhere in the country, but when value-based contracts first started coming onto the scene the question that arose was if and how if a drug failed. the payer ends up paying $0 or getting a 100% discount on the cost of the drug; So is every Medicaid program in the country priced at $0? And so the purpose of Medicaid’s multiple best price rule was to address that. But I think we see that there are some points that need to be clarified.

In addition to codifying the multiple best price rule, the MVP law will also define some important terms that are not currently defined in the regulation or elsewhere in the statutory law. It defines the average producer price and the average selling price of a drug; both of these are crucial to calculating your best price under the Medicaid best price rule. It will then also establish value-based regulations in the anti-kickback law. Therefore, working within this program does not contradict this. And this is something we pay a lot of attention to.

Also on the Medicaid front, there’s a model that was recently announced (Center for Medicare and Medicaid Innovation) – I don’t believe anyone has launched that yet – but it’s the Cell and Gene Therapy (CGT) Access Model, the CGT Access Model. This is essentially a multi-state contracting approach. What this model would do is CMS would negotiate a value-based contract for these high-cost cell and gene therapies, and states would then have the option to sign the contract negotiated by CMS on its behalf, regardless of the therapy. Maybe it’s gene therapy for sickle cell. CMS would go out and negotiate all the terms, and that would be a form of contract that Medicaid would then qualify for. This was just announced in September or the end of August, and it’s something we’ve been looking at as well, especially considering… we want to make sure these patients have access to high-cost medicines.

Given the population covered by Medicaid, what is the importance of implementing value-based agreements to expand access to care?

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

As we know, Medicaid programs often operate on very tight budgets. There isn’t much room for movement. Even if it’s a big budget, they’re really just covering the expenses they have, and they’re not in a good position to cover the cost of a treatment that doesn’t work, especially when we’re talking about cell and gene therapies. where the cost is hundreds of thousands or millions of dollars.

Actually, for us this is a matter of equality. We want to see these policies (CGT Access Model and MVP Act) succeed so that Medicaid programs have the tools they need to facilitate access for their beneficiaries.