Medicaid VBPs for Patients

Summary#

This bill, the "Medicaid VBPs for Patients Act," changes how Medicaid and related programs can use value-based purchasing (VBP) for drugs. It adds rules so manufacturers may report multiple "best price" points for the same drug strength when the manufacturer offers a VBP to all States. The bill updates the definition of average manufacturer price (AMP) to require reporting of refunds, rebates, reimbursements, free goods, or withheld payments that are triggered when a patient fails to meet outcomes or measures in a VBP. It also treats installment payment VBPs as if the full price were paid in the first installment for AMP purposes. The bill links the term "value-based purchasing arrangement" to an existing federal regulatory definition and requires the Department of Health and Human Services (HHS) to complete rulemaking within 180 days. For Medicare, the bill directs that Average Sales Price (ASP) calculations exclude the same amounts excluded from AMP for drugs under VBPs when manufacturers elect to report multiple best prices. HHS must issue guidance within 180 days about using VBPs for inpatient drugs and how States can enter cooperative agreements and transfer funds. The bill adds an exception to the federal antikickback statute for remuneration a manufacturer or third party provides to a State under a VBP when a patient fails to meet contract outcomes. The HHS Inspector General must complete related rulemaking within 180 days. Finally, the Comptroller General (GAO) must study and report by June 30, 2029 on how VBPs affect access, outcomes, program interactions, State spending, and prices.

What it means for you#

  • Patients: States may use VBPs that tie payment to patient outcomes; the bill requires study of whether that improves access and outcomes. No immediate change to coverage is mandated by the bill text.
  • State Medicaid programs: The bill makes it easier to use VBPs, allows States to cooperate with each other, and requires HHS guidance on inpatient drug VBPs.
  • Drug manufacturers: Manufacturers may report multiple best-price points for the same drug if they offer the VBP to all States. Certain VBP payments tied to outcomes must be reported in AMP, and installment payments may be treated as paid up front for AMP.
  • Medicare: For drugs under VBPs where multiple best prices are reported, ASP calculations must exclude amounts excluded from AMP under the bill.
  • Federal agencies: HHS and the HHS Inspector General must issue rulemaking or guidance within 180 days. GAO must study and report by mid‑2029 on VBP effects listed in the bill.

Expenses#

No publicly available information.

Proponents' View#

The bill text directs GAO to study whether VBPs "facilitate patient access to covered outpatient drugs, improve patient outcomes, lower overall health system costs, and lower costs for patients in Federal health care programs." The GAO study list in the bill also shows sponsors want to examine access to transformative therapies (including rare disease gene therapies), impacts on socioeconomic disparities, effects on the Medicaid rebate program, the 340B program, Medicare Part B, State Medicaid expenditures, and prices in States that do not enter VBPs.

Opponents' View#

No publicly available information.