ASCO Weighs in on CAP Demo in Drug Pricing Proposal

January 2, 2019

As part of the Trump Administration’s continuing effort to address the cost of prescription drugs, the Centers for Medicare & Medicaid Services (CMS) recently solicited input on a proposed new pilot program to test mechanisms for reducing drug costs. The International Pricing Index Model (IPI) for Medicare Part B drugs proposes sweeping reforms that would, in part, benchmark some Medicare Part B drug prices against other countries and change how providers get paid for administering drugs to patients.

On December 31, 2018, ASCO provided feedback to CMS Administrator Seema Verma highlighting the role physicians play in assuring the most appropriate utilization of cancer drug treatments and cautioning against implementing any strategies to contain costs that may limit patient access to care. 

“ASCO shares the Agency’s concern regarding the rising cost of drug prices,” said ASCO President Monica M. Bertagnolli, MD, FACS, FASCO, in the letter. “We want to continue working with CMS on solutions that promote patient access to oncology care and support the financial sustainability for different models of oncology practices. … We remain concerned about cost-centric utilization management strategies, like step therapy, that will threaten the quality of care for patients with cancer by limiting patient access to the most appropriate treatment.”

Reviving the Competitive Acquisition Program

In addition to establishing IPI, the proposed model would revive and revise the Competitive Acquisition Program (CAP), requiring physicians in the demonstration model to acquire drugs from vendors selected in a competitive bidding process. The model also attempts to incentivize participating providers by paying them a flat management fee. Some aspects of the CAP demonstration model proposed in IPI are consistent with ASCO recommendations, but the society cannot support the mandatory nature of the current proposal,  mandated payments to vendors, or the authorized use of utilization management policies like step therapy. ASCO strongly opposes any policies that require a patient with cancer to try and fail on a treatment before they can access the preferred therapy.

ASCO’s comments on the CAP demonstration and management fee components of the proposal emphasize:

  • The need to ensure fair and adequate reimbursement for the full range of services and products that are necessary to provide modern oncology care.
  • That a CAP demonstration model must protect patient access to care when coinsurance issues arise.
  • That oncology practices should be allowed to participate in CAP as vendors, with the ability to purchase drugs on behalf of their own practice. CMS should also allow for regional and national vendors to ensure competition.
  • That the newly calculated Average Sales Price rates should only be applied within the CAP demonstration area and not to drugs or providers that are not included in the demonstration.

Clinical Pathways Address Utilization Management Without Hindering Access to Care

Instead of step therapy, or other restrictive approaches to utilization management, ASCO’s comments urge CMS to consider using high-quality clinical pathways in any CAP demonstration model. ASCO has long stated that high-quality clinical pathways ensure consistent and coordinated delivery of evidence-based care—regardless of setting or geographic location—and when properly designed and implemented, serve as an important tool in improving care quality and reducing costs.

“Overall, the use of clinical treatment pathways in lieu of more traditional utilization management techniques will lead to higher quality outcomes for patients while encouraging oncology care providers to make care decisions based on the best evidence available and avoiding drug wastage,” writes Dr. Bertagnolli.

Read the full Letter to Administrator Verma.

ASCO will continue to work with CMS to implement drug pricing policies that benefit Americans with cancer. Stay tuned to ASCO in Action for updates on this issue and other breaking cancer policy news.