Drug Channels delivers timely analysis and provocative opinions from Adam J. Fein, Ph.D., the country's foremost expert on pharmaceutical economics and the drug distribution system. Drug Channels reaches an engaged, loyal and growing audience of nearly 100,000 subscribers and followers. Learn more...

Wednesday, May 27, 2020

Drug Channels News Roundup, May 2020: COVID-19 and Formularies, Retail-to-Mail Trends, ABC on Biosimilars, and Social Distancing the CVS Way

FWIW: Summer is finally here. Before you venture outside for your lockdown barbeque, check out these noteworthy items off the Drug Channels grill:
  • Payers predict how COVID-19 will affect formularies
  • Our analysis of the 2020 retail-to-mail shift
  • AmerisourceBergen profiles biosimilars
Plus, CVS pharmacy offers a clever way to measure appropriate social distancing.

P.S. Join the nearly 9,400 followers of my curated links to neat stuff at @DrugChannels on Twitter. My recent tweets have highlighted: hospital profits, drug spending, prior authorization at specialty pharmacies, legal issues for drug importation, private equity funding for a start-up PBM, physicians vs. PBMs, trends in Google Trends, and more. I continue to tweet under-the-radar stories about how the coronavirus is affecting drug channels and healthcare spending.

Friday, May 22, 2020

Electronic Prescription Management and Enrollment for Specialty Medications—Expanding Provider Adoption of Tech-Enabled Hub Services

Today’s guest post comes from Kyle Grimslid, Market Development Director at CoverMyMeds.

Kyle describes the complications that providers and patients encounter in the specialty prescription process. He describes how AMP: Access for more Patients™ enhances access, affordability and adherence—including a reported 27% reduction in time to therapy.

Click here to learn more about how CoverMyMeds and RxCrossroads by McKesson are using technology to solve patients' medication access challenges.

Read on for Kyle’s insights.

Thursday, May 21, 2020

Why Do CVS And Express Scripts Rely on Secretive Private Companies to Run Their Copay Maximizer Programs?

In Copay Maximizers Are Displacing Accumulators—But CMS Ignores How Payers Leverage Patient Support, I explained a new Centers for Medicare and Medicaid Services (CMS) final rule regarding health plans’ use of copay accumulator adjustment. I also highlighted why plans have responded to the negative patient impact from accumulators with copay maximizer programs.

However, maximizers are being implemented very differently from accumulators.

The two largest PBMs—CVS Health’s Caremark and Cigna’s Express Scripts—have each partnered with secretive and independent private companies to operate specialty drug maximizer programs for their plan sponsor clients. What’s more, at least one of these private companies earns fees equal to 25% of the manufacturer’s copay support program.

These arrangements are very odd. Why do multi-billion-dollar public companies rely on these private companies to administer their maximizer programs? Why do these small companies deserve such outrageous fees? Why are beneficiaries required to affirmatively sign up with the companies—or face ludicrous costs that far exceed their plan’s out-of-pocket maximums? Does any oversight exist for these arrangements?

Here’s what I managed to uncover about these businesses. See what you think.

Tuesday, May 19, 2020

Copay Maximizers Are Displacing Accumulators—But CMS Ignores How Payers Leverage Patient Support

COVID-19 has not stopped the wheels of policy bureaucracy from grinding. Last week, the Centers for Medicare and Medicaid Services (CMS) released its final Notice of Benefit and Payment Parameters for the 2021 benefit year. You’ll find the document links below.

This final rule permits insurers to exclude the value of a pharmaceutical manufacturer’s copay support program from a patient’s annual deductible and out-of-pocket maximum obligations.

Translation: CMS has confirmed that insurers have the option to use copay accumulator adjustment for their pharmacy benefit programs.

Patients on specialty drugs lose big from accumulators, while plans profit from the lower spending that results. Consequently, copay maximizers have emerged as a more patient-friendly alternative to accumulators. Below, I remind you of the math behind these alternatives.

Plan sponsors are publicly denouncing copay support programs—while they’re privately embracing them. CMS’s final rule ignores the troubling reality behind maximizers and accumulators: They encourage plans to use pharmacy benefit deductibles as a scheme that allows payers—not patients—to reap the greatest benefits from a manufacturer’s patient support program.

Thursday, May 14, 2020

The State of Specialty Pharmacy in 2020 (video)

I received good feedback on Tuesday's video about retail pharmacy.

So below, you'll find another brief video excerpt from my May 1 Industry Update and COVID-19 Impact video webinar.

In this clip, I highlight the growth and consolidation dynamics facing the specialty pharmacy industry. I also discuss the competitive challenges facing smaller pharmacies.

Never fear, Drug Channels traditionalists. I'll be back with a new article next week.

Tuesday, May 12, 2020

The State of Retail Pharmacy 2020 (video)

Thanks to everyone who joined me for DCI's Industry Update and COVID-19 Impact video webinars. I enjoyed putting these events together and hope you benefited from watching them. If you missed these two live events, click here to find out how you can watch the replays.

Below is a brief video excerpt from my May 1 video webinar. In this clip, I summarize the perilous competitive dynamics facing retail pharmacies.

P.S. We are still experimenting with how best to use our new Drug Channels Video platform. Please drop me a line with any feedback or suggestions.

Friday, May 08, 2020

Surprise! Brand-Name Drug Prices Fell in 2019 (rerun)

This week, I’m rerunning some popular posts while I prepare for today’s video webinar: Industry Update and COVID-19 Impact: PBMs & Payers.

Click here to see the original post and comments from January 2020.

Manufacturers recently announced list price increases for many brand-name drugs. The typical increase was about 5%. Judging by recent history, these moderately higher list prices will translate into another year of falling brand-name drug prices in 2020.

This surprising conclusion comes from our analysis of SSR Health data on prices for more than 1,000 drugs. Details below.

SSR Health data reveal that list prices for brand-name drugs rose by about 5% in 2019. However, net prices (after rebates and discounts) decreased by -3.1%. Drug makers discounted their brand-name drug list prices by an average of 45%.

Too many journalists and politicians remain committed to the false narrative of “skyrocketing drug prices.” In 2020, Congress may again take up drug price legislation. Let’s all hope that our country builds its public policies based upon accurate facts and reliable data. Hope has to triumph over experience eventually.

Thursday, May 07, 2020

Express Scripts vs. CVS Health: Five Lessons From the 2020 Formulary Exclusions and Some Thoughts on Patient Impact (rerun)

This week, I’m rerunning some popular posts while I prepare for this Friday’s video webinar: Industry Update and COVID-19 Impact: PBMs & Payers.

Today's rerun highlights one of the most effective tactics that PBMs have developed to extract deeper discounts from brand-name drug makers. COVID-19 seems likely shift the U.S. payer mix away from commercial health plans. Expect even tighter formulary management and more restrictions as PBMs work even harder to cut costs for their plan sponsor clients.

Click here to see the original post and comments from January 2020.

For 2020, the two largest pharmacy benefit managers (PBMs)—Express Scripts and the Caremark business of CVS Health—have again increased the number of drugs they have excluded from their standard formularies. The 2020 formulary exclusion lists are available below for your downloading pleasure.

Below, I highlight my key takeaways from the 2020 lists:
  • The number of exclusions
  • Management of specialty drugs
  • Indication-based formularies
  • The slow adoption of biosimilars
  • The PBMs’ patient-unfriendly exclusions in the hepatitis C category
Formulary exclusions have emerged as a powerful tool for PBMs to gain additional negotiating leverage against manufacturers. The prospect of exclusion leads manufacturers to offer deeper rebates to avoid being cut from the formulary. Exclusions are therefore a key factor behind falling brand-name net drug prices.

Read on for a look at this year’s exclusions along with some closing thoughts on what exclusions mean for patients.

Wednesday, May 06, 2020

Why Part D Plans Prefer High List Price Drugs That Raise Costs for Seniors (rerun)

This week, I’m rerunning some popular posts while I prepare for this Friday’s video webinar: Industry Update and COVID-19 Impact: PBMs & Payers.

Part D reform has faded from the policy debate. This rerun explains why it is still needed. FYI, this is my favorite article from 2020 (so far).

Click here to see the original post and comments from January 2020.

Our high-list-price/high-rebate system remains a fundamental source of warped incentives and cascading problems within the Medicare Part D program.

For proof, check out the previously unpublished data below on market share for products that treat hepatitis C. Despite manufacturers offering products with lower list prices, Medicare Part D plans have rejected the therapeutically identical but lower-priced versions of these drugs.

List prices significantly affect seniors’ out of-pocket costs, so Part D plans are needlessly costing many of them thousands of dollars. The federal government's Medicare spending is also unnecessarily higher.

Anyone concerned about drug prices should pay close attention to this situation. Part D plans and seniors who don’t need specialty medications are benefiting, while seniors who need treatment with specialty medications are ripped off. Just another day inside the gross-to-net bubble!

Tuesday, May 05, 2020

Express Scripts + Prime Therapeutics: Our Four Takeaways From This Market Changing Deal (rerun)

This week, I’m rerunning some popular posts while I prepare for this Friday’s video webinar: Industry Update and COVID-19 Impact: PBMs & Payers.

I suspect this deal will remain profitable for the participating companies even as COVID-19 alters the US. prescription payer mix. Click here to see the original post and comments from January 2020. National market shares for the largest PBMs in 2019 appears as Exhibit 88 of our 2020 Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers.

P.S. Sorry that today's meme is one day too late for Star Wars day.

Just before the holidays, Cigna’s Express Scripts business announced a market-changing deal with Prime Therapeutics. Click here to read the press release.

There's been very little written about this transaction, though it has potentially major implications. Below, I share my thoughts on the following topics arising from the deal:
  • Implications for manufacturers and pharmacies
  • The role of the secretive Ascent Health Services
  • What this all means for Walgreens
  • Why the Federal Trade Commission won’t challenge the deal
A few weeks ago, I explained why integrated insurer / PBM / specialty pharmacy / provider organizations are poised to restructure U.S. drug channels. The Express Scripts / Prime deal signals that the channel will continue its amazing pace of reinvention.

The scale, scope, and interconnectedness of today’s market participants make the system increasingly resistant to massive disruption from either external players like Amazon or a government takeover. Like it or not, the channel will continue to gain power and extract profit. Read on and see if you agree.

Monday, May 04, 2020

Insurers + PBMs + Specialty Pharmacies + Providers: Will Vertical Consolidation Disrupt Drug Channels in 2020? (rerun)

This week, I’m rerunning some popular posts while I prepare for this Friday’s video webinar: Industry Update and COVID-19 Impact: PBMs & Payers.

Life was very different when I originally published today’s article. 2020 is not turning out to be quite what any of us expected. However, the pandemic has exposed some intriguing pros and cons of vertical consolidation. Click here to see the original post and comments from December 2019.

The largest insurers, PBMs, and specialty pharmacies have now combined into vertically-integrated organizations. As I explain below, these companies have also been rapidly integrating with healthcare providers.

I also provide an updated look at these companies and highlight strategies that they are using—or could use—to control the channel. I believe that these insurer / PBM / specialty pharmacy / provider organizations are poised to restructure U.S. drug channels by exerting greater control over patient access, sites of care/dispensing, and pricing.

If they can effectively coordinate their sprawling business operations, they will pose a substantial threat of disruption to the existing commercial strategies of pharma companies.

Will they succeed by better managing care and costs, or merely by extracting higher profits from our convoluted system?

Friday, May 01, 2020

Elsevier: Challenges and Trends to Watch in 2020 (Guest Post)

Today’s guest post comes from Trygve Anderson, Vice President of Commercial Pharmacy at Elsevier.

Trygve discusses trends and challenges to watch in 2020, including drug pricing transparency, the approval and interchangeability of biosimilars, and stakeholder access to timely and accurate data.

Learn more about Elsevier’s information analytics capabilities from its video: Evaluating Drug Data Yields Business Value.

Read on for Trygve’s insights.