Republican leaders of the Senate and House Committees with oversight of the Centers for Medicare and Medicaid Services (CMS) are raising concerns with a recent decision to severely restrict coverage of a U.S. Food and Drug Administration (FDA)-approved Alzheimer’s treatment and any similar future treatments, in a disturbing break with precedent.
In a letter to CMS, Senate Finance Committee Ranking Member Mike Crapo (R-Idaho), Senate Health, Education, Labor and Pensions Ranking Member Richard Burr (R-North Carolina), House Ways and Means Republican Leader Kevin Brady (R-Texas) and House Energy and Commerce Republican Leader Cathy McMorris Rodgers (R-Washington) outline how the decision departs from precedent and creates dire new concerns, and ask for information on how CMS arrived at its decision.
From the letter:
“On various fronts, the national coverage determination issued by the agency strays from precedent, subordinates the clinical judgment and expertise of the Food and Drug Administration, and suggests a problematic new standard that risks chilling innovation and jeopardizing access to the cutting-edge treatments of the future. We urge CMS to reconsider this approach and to operate within the bounds of its statutory authorities and directives, which this latest decision oversteps.”
The members outline a number of problems with the final decision, including that:
- CMS has never before restricted Medicare access (through CED) to an FDA-approved indication (use) of a drug or biologic.
- The decision restricts access to an entire class of FDA-approved drugs based on a single drug’s clinical trial results.
- CMS’s decision inappropriately supplants FDA’s authority and exceeds its own.
- Under the decision, many beneficiaries will receive a placebo, and some may even need to pay cost-sharing for it.
- CMS has never before disadvantaged drugs approved via FDA’s accelerated approval pathway, which has led to hundreds of approvals for drugs treating cancer, HIV/AIDS, and other life-threatening conditions. The decision risks deterring and eroding the pathway, meaning delayed access to treatments.
- Full-benefit dually eligible (Medicaid and Medicare) beneficiaries will have no access to these drugs outside of the stringent CED standards, even though other Medicaid enrollees will have access to these products (potentially subject to utilization management).
- This decision could chill investment in high-risk R&D, particularly for Alzheimer’s treatments.
Full text of the letter is available here.