Senate Finance Committee members from both parties told the CMS on Thursday not to go forward with a Medicare Part B initiative to change how hospitals and doctors are reimbursed for outpatient drugs.
The CMS announced the mandatory change last month to criticism from some doctors and insurers as well as the pharmaceutical lobby. The five-year pilot program borne out of the Center for Medicare and Medicaid Innovation would, starting this year, decrease the percentage of a drug's average sales price paid to providers from 6% to 2.5% while adding a flat payment of $16.80 per drug a day.
Later, the program would include other options for value-based payment for medication, including changing payment based on clinical effectiveness and setting a standard rate for therapeutically similar drugs.
Republicans on the Senate Finance Committee urged the CMS in a letter to withdraw the rule because the widespread and drastic changes could impact care for some patients. They said the agency did not consult with outside experts when changing the rule and only had “a hunch” that it would work.
“We are perplexed by the scope of the proposed experiment as it would require providers in the vast majority of the country to participate in at least one dramatic payment change,” they said. “The unprecedented scope is especially troubling considering the policies could decrease the quality of beneficiary care and increase Medicare costs.”
The CMS has said the change would not keep doctors from prescribing the best treatments. The reform idea, which policy analysts have praised, was inspired by a Medicare Payment Advisory Commission report outlining concerns that providers are more likely to prescribe more expensive drugs because of the higher cost-sharing amount.
In their letter, committee Democrats said the model's changes are too “significant and complex” to implement without more research and added measures to protect consumers.
The CMS needs to be sure beneficiaries would still have access to any needed medications, prevent incentives to shift care from community-based practices to hospital outpatient departments and not discourage participation in existing payment reform models, they said.
They commended value-based payment methods in general but said “stakeholder involvement, including direct patient input, is essential to the successful development and application of value-based purchasing tools.”