On Friday, August 9, the Maryland Prescription Drug Affordability Board released its draft Upper Payment Limit Action Plan.
If the Maryland Prescription Drug Affordability Board determines that a drug “has led or will lead to affordability challenges for the State health care system or high out of pocket costs for patients”, the Board may put forth policy recommendations including the implementation of an upper payment limit (UPL). Prior to doing so, the UPL Action Plan must be approved by the Legislative Policy Committee within 45 days of its submission.
Currently, UPLs in Maryland will apply only to government health plans. Legislation was introduced but not passed this year to expand the scope of applicability.
Read the Draft UPL Action Plan HERE.
No time to read the Action Plan? Here’s a summary:
The Good:
- UPL-setting is a multi-step process with multiple opportunities for input from stakeholders.
- The Board is meant to set a UPL in a way to minimize adverse outcomes and the risk of unintended consequences.
- The Board is meant to prioritize drugs that have a high proportion of out-of-pocket costs compared to net cost of the drug.
- The draft Action Plan acknowledges that a UPL may not always be an appropriate or preferred policy solution and suggests that other policy actions may be recommended.
The Bad:
- Processes can move concurrently. After a preliminary report determining a drug to be unaffordable is issued, the procedures for setting a UPL may begin. A UPL may be set at the same meeting that the final cost review report is adopted.
- No specific policy actions other than UPLs are mentioned as options, let alone detailed, in the Action Plan.
- Several methodologies and factors listed for possible consideration when setting the UPL may cause concern for patients and providers. Some fail to take into consideration the unique needs of each patient. Others seek to reference health care systems in other countries or limit cost/utilization based on an arbitrary proportion of state health plan budget.
- The plan does not indicate how the UPL will result in patient savings.
The Ugly:
- Maryland’s PDAB is not prohibited from using the QALY or QALY-like metrics in their processes, and the Draft Action Plan lists cost effectiveness analysis as one option for determining UPLs. The QALY and QALY-like metrics are widely viewed as discriminatory.
- Despite the Board seeking to “minimize the risk of unintended consequences”, no guidance is provided relating to analyzing potential impacts on access or ensuring continued access to treatments.
- While the Action Plan says the Board may make policy recommendations beyond the setting of a UPL, the Board has shown little interest in considering other tactics. In fact, at its last meeting, the Board brushed past a staff presentation offering additional policy options, suggesting it may be ready to consider them for next year’s report to the legislature.
Although time is short, stakeholders do have an opportunity to comment on the draft UPL Action Plan. Comments are due August 26 and can be submitted to: comments.pdab@maryland.gov.