Medicare gets input on revamping Part B drug program


The Centers for Medicare & Medicaid Services has an uphill climb if it is hoping to sell the idea of a revamped competitive acquisition program (CAP) for prescription drugs administered in the office under Medicare Part B.

Pills and capsules atop a spread of $100 bills Kenishirotie/Thinkstock

The CMS has been seeking comments on bringing the program back. Given the responses to the proposal for simply revising the program without specific operational details as presented in the American Patients First blueprint for lowering drug prices and costs, the final program design will need to be something special to attract physicians to participate.

Under the original CAP, participating physicians would order drugs from an approved vendor, who would then bill Medicare and collect copayments from the beneficiary. The original program was in effect for 18 months and ended on Dec. 31, 2008, after it had little participation and faced other concerns.

More recently, the Medicare Payment Advisory Committee (MedPAC) recommended a revised version of the program, which they dubbed the Part B Drug Value Program (DVP). Under this proposal, private vendors would acquire drugs at lower prices using various negotiation tools, and physicians would be encouraged to make more value-based use decisions based on opportunities for shared savings under Part B.

The CMS is asking for feedback in its proposed 2019 update to the outpatient prospective payment system on a wide range of questions on how the revamped CAP program should be designed, including program design, which suppliers and drugs to include, how to encourage participation, how to structure outcomes-based arrangements, and whether indication-based pricing should be used.

Any demonstration project to test the provisions of a revised CAP program “must be voluntary, as we cannot predict the outcome and the impacts on patients and practice,” officials from the American College of Rheumatology insisted in a July 13 comment letter. “Making any programs and demonstrations voluntary, rather than compulsory, is centrally important to protecting patients.”

The ACR noted that it has “concerns regarding recreating a [CAP] for Part B drugs that was previously unworkable,” adding that it would “oppose a CAP program if it were unchanged or similar to the previous program, or if it would not ensure adequate protections for patient access to medicines.”

The ACR expressly opposed any CAP program that would include utilization management techniques such as prior authorization, step therapy, or other formulary limitation methods.

The American Medical Association said in July 16 comments on the blueprint that a “hasty resurrection of the original CAP with a few cosmetic changes is bound to fail. A CAP descendant cannot succeed without a significant redesign, consultation with earlier program participants, and adequate public input. Any successful redesign will need to provide physicians with a true choice of whether to participate or not; ensure that patient access to necessary drugs is not harmed; and avoid the temptation to add burdensome new administrative procedures aimed at enhancing CAP vendors’ negotiating power and cost-constraints.”

The AMA raised a number of questions that would need to be addressed to get the program up and running in the areas of patient protections and operational issues.

The American Academy of Dermatology Association offered support for the current Part B payment scheme of average sales price plus 6%, but said simply on CAP that it “should be restructured to provide greater flexibility and appeal to providers and vendors.”

The Alliance of Specialty Physicians offered a suggestions in its comments, including

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