Contentious Alzheimer's Drug Likely to Get National Coverage Plan, CMS Says

Kerry Dooley Young

July 13, 2021

On Monday, federal officials announced they are seeking to establish a national coverage policy for aducanumab (Aduhelm) for Alzheimer's disease (AD), a process that will take until next year to complete.

The Centers for Medicare & Medicaid Services (CMS) said it will accept public comments about how Medicare should cover aducanumab through August 11. The agency intends to post a draft decision memo on its coverage approach by January 12, 2022 and then finalize this policy by April 12. Coverage decisions about aducanumab now are being made at the local level by Medicare's administrative contractors, CMS said in a press release.

The announcement followed separate public calls for such a review by America's Health Insurance Plans (AHIP) and the Alzheimer's Association.

On June 30, AHIP submitted a formal request to the CMS. In it, AHIP requests that CMS take "swift action" on a national coverage determination for aducanumab. In the request, the organization specifically urged CMS to use a policy known as coverage with evidence development (CED) for Aduhelm.

This CED approach would allow access for patients considered most likely to benefit from the drug while Biogen continues research needed to definitively show its clinical benefit, said AHIP Chief Executive Matt Eyles.

As reported by Medscape Medical News, last month the US Food and Drug Administration (FDA) approved aducanumab based on data suggesting the drug might slow AD progression using the surrogate marker of a reduction in amyloid plaque.

The FDA's accelerated approval letter set a 2030 deadline for Biogen to produce evidence from a phase 3 clinical trial definitively proving the drug's efficacy.

Hefty Price Tag

Even if Biogen meets the FDA's deadline, patients with AD, their families, clinicians, and insurers likely will wrestle for years with questions about whether to use this costly drug without clear evidence of benefit. The drug is estimated to cost $56,000 per year.

In addition, patients taking the drug will be required to undergo MRI scans to monitor for brain swelling or bleeding, complications that were experienced by those participating in previous studies of the drug, Eyles noted in his letter to CMS, which AHIP provided to Medscape Medical News.

About 80% of those eligible for aducanumab in the US are enrolled in Medicare, write James D. Chambers, PhD, MPharm, Tufts University, Boston, Massachusetts, and co-authors in a June article in the journal Health Affairs . Like AHIP, these authors also recommended CMS consider the CED path for the drug.

CMS has used the CED approach since 2003 to evaluate interventions such as amyloid PET for clinical evaluation of AD to implantable cardioverter defibrillators.

Applying CED to aducanumab "would provide the medical community, patients, caregivers, and payers with additional information long before the FDA's required post-approval studies are completed," Chambers and co-authors write. "It would also ensure that data on every patient treated would add to the knowledge base about how aducanumab impacts patient outcomes such as cognition, function, and quality of life," they add.

In the AHIP request to CMS, Eyles also noted that an independent review organization, the Institute for Clinical and Economic Review (ICER), said the evidence from studies done to date on aducanumab is "insufficient" to show a net health benefit for patients with mild cognitive impairment due to AD or mild AD.

At the ICER meeting, which will take place on Thursday, one of ICER's expert panels, the California Technology Assessment Forum, said it will further consider all of the available scientific data on aducanumab and vote on a series of questions about its efficacy and value.

ICER's reports have clout because insurers use its recommendations to help determine how to cover drugs and medical treatments. Among the questions ICER has posted online ahead of the meeting is one about the relative effects of aducanumab plus supportive care vs supportive care alone.

"Dark Irony"

Even as the medical community waits for Biogen to present clear evidence of a benefit for aducanumab, clinics specializing in AD may get a financial boost, said Jason Karlawish, MD, professor of medicine, medical ethics, health policy, and neurology at the University of Pennsylvania's Perelman School of Medicine, Philadelphia, and co-director of Penn's Memory Center.

Some clinicians see the arrival of the drug as a "win" for the field despite lingering concerns about its approval, said Karlawish at a Monday panel discussion held by the nonprofit Hastings Center, a bioethics research institute. Karlawish is a fellow at Hastings.

In May, Karlawish published an article in STAT titled ​​"If the FDA approves Biogen's Alzheimer's treatment, I won't prescribe it." Karlawish told Medscape Medical News that he was a site investigator for Biogen studies of aducanumab and has worked on studies sponsored by Lilly and Eisai.

During Monday's discussion, Karlawish said he had altered his view and now might be a "reluctant prescriber." He noted this shift is because of his commitment "to preserve, protect and defend their autonomy" of patients with AD.  

He also noted the drug could draw more money into the field to help care for patients  with AD by providing increased access to diagnostics. Additionally, funds provided to clinics for administering aducanumab will aid specialty memory centers, "which have been basically impoverished since their creation," Karlawish said.

"There is a dark irony that it takes a questionably beneficial drug to bring in the revenue to finally get memory centers up and functioning," Karlawish said.

Karlawish said there needs to be "a larger conversation about how a big, vast and problematic disease is being treated."

Aducanumab's approval shows that diseases in the US are not fully considered as diseases until they have "a business model, and much of that business model relies on the pharmaceutical industry," he noted.

Woodcock's "Personal Commitment"

Last week, the FDA took two highly publicized steps to address criticism of its handling of the aducanumab approval. It revised the drug's label to limit its use to patients with mild cognitive impairment likely related to AD or those in the mild stages of the disease.

In addition, Janet Woodcock, MD, the FDA's acting commissioner, took to Twitter and posted a letter she sent to the Office of the Inspector General (OIG) that called for a federal investigation into the drug's approval that would examine agency staff interactions with Biogen.

AHIP spokesperson Kristine Grow said on Monday that her organization is still seeking a national Medicare coverage decision, but that the label revision was a "step in the right direction."

"Patients with Alzheimer's disease, and their families and caregivers, deserve safe, effective treatments. We applaud the FDA for this label adjustment, which brings indicated patients a bit closer to those included in clinical trials," Grow told Medscape Medical News.

"At the same time, we remain concerned about the limited clinical evidence demonstrating efficacy and the serious safety risks that aducanumab poses for patients. We look forward to additional information from the FDA and other regulators, including CMS' coverage guidance for patients who are Medicare eligible," she added.

The controversy surrounding the approval of aducanumab is drawing more attention to the lack of a confirmed FDA commissioner. But in her letter to OIG, Woodcock writes as if she intends to remain at the helm of the agency for at least a while longer. She writes in her letter that OIG has her "personal commitment" that the FDA will fully cooperate if the investigative unit decides to undertake a review.

Woodcock also urged that a review be conducted as soon as possible, noting "should such a review result in actionable items, you also have my commitment to addressing these issues."

A former FDA adviser who resigned over the agency's handling of aducanumab said Monday there needs to be a broader investigation of the FDA's actions.

Attending the Hastings Center event was Aaron S. Kesselheim, MD, JD, MPH, of Harvard Medical School, one of three former members of an FDA advisory committee who resigned over the agency's handling of aducanumab. Kesselheim told Medscape Medical News that he has no financial relationships to disclose in connection with this discussion.

"I would suggest that instead all aspects of this approval process should be investigated," Kesselheim said, including the relationship between FDA and Biogen.

Karlawish said he was also concerned that Woodcock's request for an investigation was "very narrow," and noted members of Congress have said they are examining the FDA's handling of this drug.

In a July 9 joint statement, House Committee on Energy and Commerce Chairman Frank Pallone Jr (D-NJ), and House Committee on Oversight and Reform Chairwoman Carolyn B. Maloney (D-NY) said they were "pleased" by Woodcock's announcement, but they will keep digging into ongoing questions about the drug. In their view, the OIG review of FDA staff interactions with Biogen officials would complement their committees' "robust investigation of this matter," they said in a statement.

"We continue to have concerns about the approval process for Aduhelm, how Biogen set its price, and the implications for seniors, providers, and taxpayers," Pallone and Maloney added.

Kerry Dooley Young is a freelance journalist based in Washington, D.C. She is the core topic leader on patient safety issues for the Association of Health Care Journalists. Young earlier covered health policy and the federal budget for Congressional Quarterly/CQ Roll Call and the pharmaceutical industry and the Food and Drug Administration for Bloomberg.  Follow her on Twitter at @kdooleyyoung.

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