![Trump Ipi Model Web](/Areas/CMS/assets/img/blank.gif)
On October 25, President Trump announced his plan to lower prescription drug prices. Under the plan’s new proposed payment system, the Centers for Medicare & 医疗补助bet8娱乐(CMS)将启动一个为期五年的试点项目——国际价格指数(IPI)模型——当国际价格较低时,医疗保险将为部分B类药物支付更少的费用. The model, 这标志着与医疗保险长期以来的药物报销方式的重大背离, will be mandatory and cover half of the providers in the country. 特朗普称该计划是一个迟来的解决方案,最终将让制药公司和外国对困扰国内患者的高药价负责. 这篇文章总结了该提案背后必须知道的细节,以及政府可能的前进道路.
The Background
Drug prices have soared in recent years, particularly for older Americans. From 2011 to 2016, Medicare fee-for-service spending for Part B drugs increased from $17.6 billion to $28 billion, representing an annual growth rate of nearly 10%. Why? Well, there are a lot of issues, particularly if you follow the money.
Simply put, 美国处方药的商业模式围绕着不透明的规则展开, a ton of regulation, implications from a global market, 最大买家(CMS)的议价能力受到限制. We saw the Trump administration respond back in May with its blueprint to lower drug prices. That blueprint was short on specifics, but the IPI announcement outlines some of the administration’s ideas.
The Details of the IPI Model
IPI模型旨在测试改变B部分药品报销是否会提高医疗保险受益人的护理质量并减少该计划的支出. The model uses a three-pronged approach:
- 它将逐步减少部分B部分药品的医疗保险报销金额,以与外国支付的价格保持一致.
- 它允许私营供应商就药品价格进行谈判,并争夺bet8网站备用和医院的业务.
- It changes the 4.3% (postsequester) drug add-on payment to a flat amount.
B部分药物是单独支付门诊药物,由供应商购买,并在bet8网站备用办公室设置管理. Currently, Medicare pays for Part B drugs based on the drug manufacturer’s average sales price (ASP) plus a 6% add-on; due to sequestration, the add-on is effectively reduced to 4.3%. Under the proposed model, when a drug’s ASP is higher than its international price, CMS will instead pay the lower international price (the “target price”). The target price will be phased in over the five-year pilot period. CMS will continue to pay an add-on per drug, though this will be a fixed amount rather than today’s ASP-based rate. 这意味着一些药物的附加支付将增加,而另一些药物的附加支付将减少, but in aggregate, CMS estimates the add-on will be comparable to the full 6% presequester rate. When all is said and done, CMS估计,这一报销变化将使B部分药品总支出减少约30%.
Under the IPI model, 医师执业和医院门诊部根据其地理区域分为两组. Providers in the test group will start to receive certain drugs from private-sector vendors; these vendors will replace providers in the “buy and bill” system. For the control group, Part B drug reimbursement is unchanged, and providers will continue to buy and bill for drugs. Participation is mandatory for providers in the test group, CMS正在考虑将参与范围扩大到其他供应商和供应商(例如.g., durable medical equipment suppliers, ambulatory surgical centers). The model will initially include single-source drugs and biologics and, over time, 是否可以扩大到包括多来源药物和在其他环境中提供的B部分药物.
The IPI model will be a pilot project run under CMS’s Center for Medicare & Medicaid Innovation (CMMI). 使用CMMI作为部署工具,特朗普政府可以绕过国会的批准,并以最小的政治或官僚摩擦向前推进.
The Reaction
This proposal represents a tidal shift in how Part B drugs are reimbursed. Many specialty providers (e.g., 肿瘤学家)依靠当前的成本加补偿来支持他们实践的关键要素和资助护理提供基础设施. Numerous provider advocacy organizations (e.g., ASCO, ACCC) have already spoken out against the proposal. But its reimbursement implications are uncertain until we see more details. Yes, providers may take a hit if the mechanics behind the plan don’t keep them whole; on the flip side, providers benefit by shifting practice risk onto private-sector vendors. Under the new model, 医疗bet8娱乐提供者得到的报酬不应低于药物的成本——这是当今常见的挑战, especially for drugs with high inflation rates. However, even with this protection, 医疗bet8娱乐提供者仍有一些风险(医疗bet8娱乐提供者仍需收取每位患者20%的共付费用)。.
该模式背后的经济学原理尚不清楚,行业分析师也不确定其有效性. 该模式的基础是一项承诺,即减少B部分报销将迫使药品制造商降低国内价格, raise prices abroad, or both. The plan does little to tackle the root cause of high pharmaceutical prices, 因此,除非实现适当的方法和参数,否则提供者的损失最大. Moreover, 如果IPI模式取消了药品折扣计划,340B供应商将面临失去所依赖的储蓄的重大风险.
The Path Forward
CMS将在2018年12月底前就拟议的IPI模型征求意见, with the feedback intended to help set the model’s parameters. 虽然该模型还处于非常早期的阶段,许多实现细节还有待解决, CMS已表示打算在2019年春季推出正式的拟议规则,并从2020年初开始进行为期五年的试点.
Although it’s still too early to tell, it seems likely that this proposal, despite all the outrage and objections it has already generated, will move forward. 相信特朗普政府将推进这一模式的理由包括:
- Campaign Promise: First, as noted in a previous blog post, drug pricing was a central tenet of Trump’s 2016 campaign platform. The administration’s drug blueprint was an initial response, and with this proposal we are starting to see the details come to fruition.
- No-Holds-Barred Approach: Second, 这届政府有一项记录,就是不顾巨大的反对,推进重大变革. 想想今年早些时候CMS是如何对340B项目宣称其权威的, 这一变化有效地将医院门诊340B药物的B部分报销减少了近30%.
- Bipartisan Support: Finally, Democrats have been pushing for negotiable drug prices for years. In 2016, the Obama administration introduced a plan to make drug prices negotiable不过,在医疗行业和共和党的反对下,该提案被放弃了. While some prominent Democrats, among them Senator Chuck Schumer, 断言这一声明(在中期选举前两周发布)似乎是一种宣传噱头, 在这个问题上,分裂的美国国会或许可以找到共同点.
In the coming months, as CMS collects comments, 关于模型实现可能性和最终参数的线索将会出现. Bottom line: this plan is a huge change, 并考虑到其潜在的财务意义(B部分药品支出减少30%)和溢出效应(更广泛地应用参考定价), it is one the entire industry will be watching.
Published November 2, 2018