Survey Finds That Best Price Stacking Proposal Could Impact Patient Access and Lead to Market Disruption

NICA Commissioned a Survey to Understand Stakeholder Perspectives on the Best Price Stacking Proposal

In May 2023, CMS released a proposed rule titled “Misclassification of Drugs, Program Administration, and Program Integrity Updates under the Medicaid Drug Rebate Program (MDRP).” The proposed rule would require that manufacturers stack all price concessions for every unit of medicine provided to separate customers throughout the supply chain in the determination of Best Price. This differs from today, where Best Price is determined by the lowest net price to a single customer.

The National Infusion Center Association (NICA) commissioned a survey to assess stakeholder perspectives on the Best Price stacking proposal and to understand potential market and patient access changes that could occur if the proposal was finalized. The survey was completed by 29 respondents that represented health plans (n=8), pharmacy benefit managers (PBMs) (n=5), healthcare providers (n=5), wholesalers (n=3), group purchasing organizations (GPOs) (n=3), and pharmacies (n=5).

Finalization of the Best Price Stacking Proposal Could Create Patient Access and Affordability Challenges

72% of respondents indicated that if the Best Price stacking proposal is finalized, their organization may make changes to key business practices that would impact patient access and affordability.

  • 69% of health plan and PBM respondents would make changes to benefit design, and 62% would make changes to formulary design.
  • 80% of healthcare provider respondents would make changes to which medications are available to patients and charges billed to payers and patients.
  • Two-thirds of GPO and wholesaler respondents would make changes to prices charged and half of GPO and wholesaler respondents would make changes to the selection and quantity of products purchased.
  • 80% of pharmacy respondents would make changes to products available, and 60% of pharmacy respondents would make changes to patient service offerings (e.g., medication adherence support).

Stakeholders Expect Market Disruption if the Best Price Stacking Proposal is Finalized

Approximately half of stakeholders expect that the finalization of the Best Price stacking rule would lead to market disruption. An additional quarter of stakeholders are unsure if finalization would result in market disruption, indicating that there are significant uncertainties around the proposal’s impacts.

  • Approximately two-thirds of health plan, PBM, and wholesaler respondents expect to experience market disruption as a result of Best Price stacking, indicating the potential for significant disruption within certain market segments.
  • Of the stakeholders who expect market disruption, none characterized the disruption as “limited.” 64% expect to experience some disruption, and 36% expect to experience significant disruption.

What Advocates Are Saying:

“While we commend CMS for continuing to propose solutions intended to reduce costs for Medicaid beneficiaries, every policy should be evaluated on its impact across the entire healthcare ecosystem to mitigate unintended consequences. It is imperative that CMS withdraw the stacking policy to protect providers and vulnerable patients who rely on access to essential treatments to optimize their health and well-being.” – Brian Nyquist, MPH, President and Chief Executive Officer (CEO) of the National Infusion Center Association (NICA).

“For instance, would the new best price rule reduce clinical and financial risk for Medicaid beneficiaries — who already face no or extremely low co-pays for prescriptions — or would it merely save the government money? And would those savings come at the cost of depressing investment in new and innovative treatments? The rule’s potential deterrent effect on drug research must not be discounted, especially since Medicaid recipients have higher rates of disabilities and chronic conditions than other covered individuals in the public and private sectors.” – Gary A. Puckrein, President & Chief Executive Officer Of The National Minority Quality Forum (NMQF)

“Incorporating the stacking of multiple discounts is not a determination of best price, but a commentary on a complex system that requires a multitude of transactions. Particularly for smaller innovator companies with limited product lines, this complex marketplace can be challenging to navigate. Incorporating aspects of not one but all transactions into the calculation of the best price can make bringing a potentially life-changing therapy to market even more challenging.” – Margarita Valdez Martínez, Director of Policy and Advocacy, American Society of Gene + Cell Therapy.