Highlights
The CMS use a risk adjustment strategy, right. So, they look at the whole population, and the numbers of patients that are treated, and determine what the actual risk is probably going to be. And in regards to ESRD prospective pay, we again have the assumption that the majority of the patients are going to receive the minimum amount of care that everybody will get, and then we make some allowances for some more severe patients just because we tend to be a little bit more conservative in that regard.
We actually use the ASP, because we’re going to be billed by providers, and again, there’s a model for that through Health and Human Services as well, CMS, Medicare, also follow that same ASP-based methodology… If it’s a new launch, there won’t be an ASP available. We will then default to an AWPbased.
Yes, [if HIF stabilizers are not included in the bundle] it would have to be an outlier payment, they’ll have to have a separate code for it, it might have to get authorized before it gets paid as well. It would be morecomplica ted, that’s for sure.
[Pricing] is not very flexible inside the bundle, that gets that price of CMS, they set that, and commercial plans like our own will follow that example, I think that’s a very safe function to go off of there. Outside of the bundle however, I think that there is probably some room to do some negotiation for producing these new agents that may not be for dialysis…
This interview with a US-based key opinion leader (KOL) provides insights into pricing and reimbursement dynamics and issues concerning anemia in chronic kidney disease, with a focus on the anticipated reimbursement of HIF stabilizers in the US.