Program

In-person AND virtual! – We are pioneering a new conference format that will connect in-person and virtual audiences to create a unique experience. Matching the innovation that comes through our members’ work, ISPOR is pushing the boundaries of innovation to design an event that works in today’s quickly changing environment. 

In-person registration included the full virtual experience, and virtual-only attendees will be able to tune into live in-person sessions and/or watch captured in-person sessions on-demand in addition to having a variety of virtual-only sessions to attend.

Could Gene Therapy Value-Based Purchasing Become Common Thanks to the New CMS Rule on Medicaid Best Price?

Speaker(s)

Discussion Leader: Mark Trusheim, MS, BS, NEWDIGS and Visiting Scientist, Massachusetts Institute of Technology, Cambridge, MA, USA
Discussants: Michael Ciarametaro, MBA, National Pharmaceutical Council, Washington, DC, USA; Dorothy Hoffman, MPP, Pfizer, New York, NY, USA; Gail Ryan, PharmD, Point32Health, Harvard Pilgrim Health Care & Tufts Health Plan, Hopkinton, MA, USA

PURPOSE: Explore the use of alternative payment approaches managing financial risk associated with curative therapies, explain how a 2021 CMS rule could lead to widespread adoption of Value-Based Purchasing Arrangements (VBPs), detail remaining challenges, and discuss how those challenges can be overcome by a combination of clever implementation and eventually, legislative enhancements to the Medicaid Drug Rebate Program.

DESCRIPTION: Durable, potentially curative cell and gene therapies with short-term treatment regimens promise to transform care for some conditions. However, by their very nature, they create significant financial risk from their up-front costs and uncertain long-term efficacy. Precision financing approaches, such as milestone contracts, warranties, and annuities, are a key tool to address this challenge. However, these financing tools present both challenges and opportunities. More importantly, understanding which precision tools to use when is critical for payers looking to manage the financial risk associated with these transformative therapies.

One of the biggest challenges is the 1990 Medicaid “best price” (MBP) rule, which ensures that the Medicaid program receives discounts at least as large as commercial payers. Payment approaches have evolved over the years and this rule now hinders the adoption of these innovative new payment models to support patient access and payer sustainability. CMS is implementing a new rule for tiered-MBP reporting based on performance.

It remains unclear to what extent the new rule will enable VBPs and other payment innovations. Even as tiered-MBP enable more aggressive risk sharing for orphan therapies other challenges remain. Implementation mechanics remain unclear, burdens on states to track outcomes may curtail state participation and some issues such as unit pricing remain unaddressed. This panel will bring both quantitative analysis and practical experience perspectives on the issues. Audience will be polled on most important challenges and solutions at the beginning and end of the workshop with time for Q&A.

Code

204

Topic

Health Policy & Regulatory