Home Health Insurance How will Medicaid pay for cell and gene therapies? – Healthcare Economist

How will Medicaid pay for cell and gene therapies? – Healthcare Economist

How will Medicaid pay for cell and gene therapies? – Healthcare Economist


One method CMS has is the Cell and Gene Remedy (CGT) Entry Mannequin. Beneath the CGT Entry Mannequin, CMS (on the federal degree) will negotiates outcomes based mostly agreements (OBAs) with producers, which is able to embody pricing phrases and outcomes to be evaluated. Then states can elect to take part within the contract phrases negotiated by CMS or they’ll decide 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 Companies. For each events, outcomes-based contracts are burdensome to implement; having CMS will assist states in implementing, monitoring, reconciling, and evaluating the monetary and scientific outcomes outlined in OBAs

What CGTs are at present deliberate for inclusion within the CGT Entry mannequin and the way a lot will they value?

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 Prescription drugs and CRISPR Therapeutics had an inventory worth of $2.2 million per affected person; “Lyfgenia” from bluebird bio was listed at $3.1 million per affected person.

What sorts of rebates might State Medicaid Companies obtain underneath the CGT Entry Mannequin?

These would come with not solely the usual Medicaid Drug Rebate Program (MDRP) rebate (a.ok.a. Medicaid finest worth) but additionally extra 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 is dependent upon the kind of rebate. Statutory Rebate (MDRP) and the negotiated assured rebate shall be paid instantly after therapy. On the finish of the 12 months, volume-based rebates might come into impact. Lastly, patient-outcome and population-outcome rebates shall be paid years after therapy administration. Notice that the affected person final result rebates will be paid yearly over time to account for circumstances the place sufferers reply to remedy however maybe not indefinitely.

What does the method appear to be 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 extra reductions or phrases apart 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 embody:

  • Execute value-based buying supplemental rebate agreements (VBP SRAs) with producers that mirror 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 fee bundle
  • Require suppliers to observe necessities for information reporting and claims submissions
  • Guarantee beneficiaries have entry to care with instate or out-of-state certified gene remedy supplier(s)
  • Guarantee vital transportation and associated journey bills to beneficiaries (NEMT)
  • Meet minimal T-MSIS information necessities

What laws created the CGT Entry Mannequin?

CMS states that:

The CGT Entry Mannequin was developed in response to President Biden’s Government Order 14087, “Reducing Prescription Drug Prices for People” and was first proposed in a report responding to the chief order directed by the Secretary of the Division of Well being and Human Providers.


How can I be taught extra?

Some useful reference materials on the CMS CGT Entry Mannequin webpage contains:



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