One method CMS has is the Cell and Gene Remedy (CGT) Entry Mannequin. Beneath the CGT Entry Mannequin, CMS (on the federal stage) will negotiates outcomes based mostly agreements (OBAs) with producers, which can embrace pricing phrases and outcomes to be evaluated. Then states can elect to take part within the contract phrases negotiated by CMS or they’ll choose out and negotiate on their very own. From CMS’s perspective, they’re hoping that the elevated buying energy will result in decrease costs (or equivalently, extra negotiated rebates). For producers, they’re hoping that the CGT entry mannequin will expedite entry for sufferers and scale back transaction prices since producers must negotiate with a lot fewer than 50 State Medicaid Businesses. For each events, outcomes-based contracts are burdensome to implement; having CMS will assist states in implementing, monitoring, reconciling, and evaluating the monetary and medical outcomes outlined in OBAs
What CGTs are presently deliberate for inclusion within the CGT Entry mannequin and the way a lot will they price?
Two CGTs for the therapy of sickle cell illness are deliberate for inclusion within the mannequin. Each have been accredited in December 2023. “Casgevy” from Vertex Prescribed drugs and CRISPR Therapeutics had an inventory value of $2.2 million per affected person; “Lyfgenia” from bluebird bio was listed at $3.1 million per affected person.
What varieties of rebates may State Medicaid Businesses obtain below the CGT Entry Mannequin?
These would come with not solely the usual Medicaid Drug Rebate Program (MDRP) rebate (a.ok.a. Medicaid finest value) but additionally further assured rebates and quantity rebates in addition to rebates paid sooner or later based mostly on affected person and inhabitants outcomes.
When would the rebates be paid?
The timing of the rebates will depend on the kind of rebate. Statutory Rebate (MDRP) and the negotiated assured rebate might be paid instantly after therapy. On the finish of the yr, volume-based rebates may come into impact. Lastly, patient-outcome and population-outcome rebates might be paid years after therapy administration. Be aware that the affected person final result rebates might be paid yearly over time to account for instances the place sufferers reply to remedy however maybe not indefinitely.
What does the method seem like from the affected person perspective?
The CGT Entry Mannequin: Overview for States presentation has a useful timeline.
If a state chooses to take part within the mannequin, can it try to barter further reductions or phrases aside from these negotiated by CMS?
If a state opts to take part within the mannequin, it should enter into an settlement with the producer that displays the phrases negotiated by CMS. Some restricted state-to-state variation could also be permitted, as could also be essential to comport with state legislative and regulatory necessities.
What do states must do to take part within the CGT Entry Mannequin?
Necessities embrace:
- Execute value-based buying supplemental rebate agreements (VBP SRAs) with producers that replicate the Key Phrases negotiated by CMS
- Pursue state plan amendments (SPAs) the place acceptable
- Set up a standardized entry coverage for included gene therapies
- Carve included gene therapies out of any inpatient cost bundle
- Require suppliers to comply with necessities for knowledge reporting and claims submissions
- Guarantee beneficiaries have entry to care with instate or out-of-state certified gene remedy supplier(s)
- Guarantee needed transportation and associated journey bills to beneficiaries (NEMT)
- Meet minimal T-MSIS knowledge necessities
What laws created the CGT Entry Mannequin?
CMS states that:
The CGT Entry Mannequin was developed in response to President Biden’s Govt Order 14087, “Decreasing Prescription Drug Prices for People” and was first proposed in a report responding to the manager order directed by the Secretary of the Division of Well being and Human Companies.
https://www.cms.gov/priorities/innovation/innovation-models/cgt
How can I study extra?
Some useful reference materials on the CMS CGT Entry Mannequin webpage consists of:
