CMS Must Provide Coverage for Breakthrough Medical Technologies

Jessica Foley, Ph.D., Chief Science Officer, Focused Ultrasound Foundation

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Patrick Hope, Executive Director of Medical Imaging & Technology Alliance (MITA)

Executive Director of Medical Imaging & Technology Alliance (MITA)

Strategic Alliance Partnership | <b>Medical Imaging & Technology Alliance (MITA)</b>

Move would support patients and encourage innovation.

For decades, the United States has prided itself as the global leader of medical innovation. From record-breaking vaccine production and advanced nuclear imaging modalities to cutting-edge focused ultrasound technologies, America has been at the forefront of the modern world’s most watershed medical breakthroughs.

Recognizing the value of the nation’s most recent medical innovations, stakeholders across the healthcare continuum found cause for celebration in early 2021 when the Centers for Medicare and Medicaid Services (CMS) finalized the Medicare Coverage of Innovative Technology (MCIT) program. As proposed, the program would eliminate the gap between Food & Drug Administration (FDA) approval processes and CMS Medicare coverage decisions for the most innovative medical devices, providing more certainty to manufacturers, more tools in clinicians’ toolboxes to treat disease, and more universal and equitable treatment options for patients.

Above all, the program aligns well with the spirit of President Joe Biden’s policy approach to healthcare: expand access, encourage innovation, and support patients grappling with life-altering diseases.

Unfortunately, despite significant enthusiasm for the program, CMS published an interim final rule on March 17, 2021, that delayed implementation of the MCIT program by 60 days. The announcement also provided a 30-day public comment period to solicit additional feedback on the rule.

In the strongest possible terms, we urge CMS to implement the MCIT program following the 60-day delay period. Here is why:

MCIT Provides a Clear – and Necessary – Public Health Benefit

Nearly five years ago, Congress passed the 21st Century Cures Act. The law established a new pathway for the FDA to fast-track the development, review, and approval of cutting-edge medical devices, which the agency designated as “breakthrough.” As the name implies, this designation is only given to medical technologies that address debilitating and largely unmet health needs.

As important as the new FDA “breakthrough” pathway was, most of the devices that received expedited approval would soon collide with a substantial roadblock at CMS. That’s because Congress, while giving the FDA the power to fast-track the approval of advanced medical devices, did not allocate similar authority to CMS to expedite Medicare coverage for these devices following their approval.

The result – referred to by some as the “valley of death” – is that breakthrough medical devices sulk in limbo as CMS determines whether to cover them, a process that takes years. Meanwhile, Medicare beneficiaries battling chronic conditions, such as diabetes, Parkinson’s disease, heart disease, and advanced cancers are unable to access the latest innovations the Medical Technology (MedTech) sector has to offer. Since breakthrough coverage often varies across regions and different public and private payers, this also creates access disparities that forces many beneficiaries to pay high out-of-pocket costs to receive care.

By providing patients with immediate, four-year coverage for “breakthrough” designated medical technologies, MCIT would bridge the gap between FDA approval and subsequent Medicare coverage of innovative diagnostics and treatments. MCIT would also support more equitable treatment access for Medicare beneficiaries and reduce out-of-pocket expenses for vulnerable patients seeking advanced care. Accounting for these advantages, the program provides clear public health benefits by increasing access to new medical innovations that can improve outcomes and reduce costs.

MCIT Would Catalyze Future Innovations Across the MedTech Sector

In years past, limited beneficiary access to breakthrough medical devices undermined the ability of clinicians and product developers to collect the requisite data needed to establish that their devices met Medicare’s “reasonable and necessary” coverage criteria. This created an incentive structure in which innovators were better off focusing on developing cheaper products that utilized existing reimbursement codes rather than truly “breakthrough” technologies that would need to clear antiquated bureaucratic approval hurdles and require new reimbursement codes and policies.

If implemented, the MCIT program would improve the current incentive structure by modernizing the CMS “reasonable and necessary” criteria to ensure innovators can obtain coverage for their devices. At the same time, it would allow these innovators to collect the necessary clinical evidence to demonstrate that their devices offer clear and discernible benefits for patients. In other words, by doing away with previous regulatory snags, the streamlined coverage process outlined by MCIT would create strong incentives for companies and investors to devote additional resources towards the development of future breakthrough products.

Taken together, MCIT represents a much-needed regulatory upgrade that further solidifies the remarkable legacy of the 21st Century Cures Act. While further expansion of the program is welcomed, implementation of the MCIT rule would hasten the equitable delivery of medical innovations to patients while ensuring that important safety and efficacy standards remain intact. It is our sincere belief CMS should expeditiously finalize this program.

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