Lawmakers Agree on Need for Medicare to Reconsider Coverage of Alzheimer’s Drugs

Lawmakers Agree on Need for Medicare to Reconsider Coverage of Alzheimer’s Drugs

At a hearing on healthcare transparency and competition, both Republican and Democrat House members expressed concern over the Centers for Medicare & Medicaid Services’ (CMS) recent decision to restrict access to Alzheimer’s drug treatments aducanumab (Aduhelm) and lecanemab (Leqembi), which inhibit amyloid. They argued that the decision hinders early intervention with the progressive disease and called for Medicare to reconsider its coverage decision. CMS had decided to cover aducanumab only when patients were enrolled in clinical trials to further explore efficacy, and a similar decision was later made for lecanemab.

Conflicting Decisions for Alzheimer’s Drugs

The FDA approved aducanumab and lecanemab under an accelerated approval process, but a congressional investigation found that the agency broke with its own protocols, such as collaborating with drugmaker Biogen on briefing documents, holding unreported meetings, and failing to gain internal consensus before engaging in such collaborations. CMS administrator Chiquita Brooks-LaSure said that part of the issue was the fact that both drugs were approved on an accelerated approval basis rather than full approval. The Department of Veterans Affairs approved coverage for lecanemab provided patients met certain criteria, including being over 65 and having been diagnosed with early-stage Alzheimer’s. Several committee members expressed concern about the conflicting decisions for the drug, which costs around $27,000 annually.

Support for Physician-Owned Hospitals

Rep. Michael Burgess is sponsoring a bill to eliminate Medicare’s prohibition on paying for services delivered at physician-owned hospitals. He argued that it is unjust that doctors can’t own hospitals when hospitals are able to own doctors. He asked Brooks-LaSure if she would work with him on the issue, and she agreed to do so.

Site-Neutral Payment Proposal

The subcommittee is considering a bill to institute “site-neutral payment,” in which Medicare would pay the same amount for particular procedures regardless of whether they’re performed in a physician’s office or hospital outpatient department. Rep. Mariannette Miller-Meeks argued that hospitals are motivated to acquire physician practices because they’re able to bill Medicare roughly double the amount that private practices can. Ashley Thompson of the American Hospital Association argued that hospital outpatient departments treat patients who are often older, sicker, and with more complex conditions, and they’re required to maintain standby capacity, as well as deliver emergency care regardless of insurance status. However, Loren Adler of the USC-Brookings Schaeffer Initiative for Health Policy argued that hospitals buying up physician practices and then being able to charge more for the same service leads to high prices for consumers and lower quality of care. He argued that Medicare rates should not pay more for services provided in hospital outpatient departments.

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