News and notes from around the interweb:

• Medicaid Specialty Drug Trend Finally Surpasses 50% of Pharmacy Spend in Most Recent Magellan Rx Management Medicaid Pharmacy Trend Report. The Medicaid Pharmacy Trend Report highlights the evolving landscape of Medicaid, made even more dynamic from the events of the last two years. The report includes an in-depth analysis of class and drug trends, forecasting of Medicaid key conditions, drugs in the pipeline, and Medicaid pharmacy economics. This is also the only detailed industry source for the analysis of Medicaid pharmacy fee-for-service (FFS) gross, net, and forecasted drug cost trends.

• Key Drugs in Specialty Pharmacy Slated to Launch in 2022. Ray Tancredi, RPh, MBA, divisional VP of specialty pharmacy development and brand Rx/vaccine purchasing at Walgreens, addresses key drugs in development that are slated to launch in 2022, key drugs in development that are slated to launch in the future of note, and some of the promising and unique medications to keep an eye on that are expected to be approved in the specialty pharmacy space.

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• 2021 Kaiser Family Foundation Employer Health Benefits Survey. The researchers found that 56 percent of small companies structured their prescription drug cost-sharing in 2021 to have at least four tiers. Meanwhile, slightly more than half of the larger companies surveyed could say the same. Nearly four out of ten large employers implemented three tiers (39 percent) compared to less than three out of ten small employers (28 percent).

• Explaining the Prescription Drug Provisions in the Build Back Better Act. On November 19, 2021, the House of Representatives passed H.R. 5376, the Build Back Better Act (BBBA), which includes a broad package of health, social, and environmental proposals supported by President Biden. The BBBA includes several provisions that would lower prescription drug costs for people with Medicare and private insurance and reduce drug spending by the federal government and private payers. The key prescription drug proposals included in the BBBA would…

• Pharmacy and PBM Leader Deloitte Consulting: Specialty Drugs Rely on Personalization for Optimal Outcomes. The high cost of specialty drugs makes it important to use companion diagnostics and other tests to make sure the drug is going to the right patient, said George Van Antwerp, MBA, managing director, Deloitte Consulting. When we look at the cost of specialty drugs, and especially some of the cell and gene therapy drugs, which are really all about precision medicine, those costs mean they have to work. They have to be focused on and personalized to the individual.

The Certified Pharmacy Benefits Specialist (CPBS) educational offering includes knowledge that is critical to effective management of the pharmacy and medical drug benefit. If you want to learn more, click here.

 News and notes from around the interweb:

• Medicaid Specialty Drug Trend Finally Surpasses 50% of Pharmacy Spend in Most Recent Magellan Rx Management Medicaid Pharmacy Trend Report. The Medicaid Pharmacy Trend Report highlights the evolving landscape of Medicaid, made even more dynamic from the events of the last two years. The report includes an in-depth analysis of class and drug trends, forecasting of Medicaid key conditions, drugs in the pipeline, and Medicaid pharmacy economics. This is also the only detailed industry source for the analysis of Medicaid pharmacy fee-for-service (FFS) gross, net, and forecasted drug cost trends.

• New Report: Anti-Competitive Practices Lead to High Prescription Drug Costs. The report, conducted by the research firm Visante, examines certain drug manufacturer anti-competitive tactics that affect many different types of prescription drugs. For example, some manufacturers of specialty drugs, which include many cancer medications, and orphan drugs employ tactics to take extra advantage of government-established monopoly status and exclusivity. In 2017, 80% of prescription drugs approved were specialty and orphan drugs, doubling from just 40% of approvals in 2001. Currently, the average launch price for drugs in these categories is more than $200,000 per patient per year.

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• 2021 Kaiser Family Foundation Employer Health Benefits Survey. The researchers found that 56 percent of small companies structured their prescription drug cost-sharing in 2021 to have at least four tiers. Meanwhile, slightly more than half of the larger companies surveyed could say the same. Nearly four out of ten large employers implemented three tiers (39 percent) compared to less than three out of ten small employers (28 percent).

• Comer: Congress Must Review PBMs’ Role in Rising Prescription Drug Prices. In his opening remarks, House Committee on Oversight and Reform Ranking Member James Comer outlined how PBMs’ consolidation has negatively affected competition in the marketplace, leading to higher drug prices for Americans. He concluded his remarks by calling on PBMs to provide greater transparency about their practices and urged further review of proposed legislation to determine any changes needed to decrease the costs of prescription drugs and benefit patients.

• As Big Pharma and Hospitals Battle Over Drug Discounts, Patients Miss Out on Millions in Benefits. Companies that want their drugs covered by Medicaid or Medicare Part B are required to offer 340B discounts, typically 25% to 50% off what they might otherwise pay. Hospitals and clinics buy the drugs at the discount and then are reimbursed by an insurance company, Medicare or Medicaid at the higher negotiated rate. The difference is kept by the hospital or clinic to use as it sees fit. The law does not require patients to benefit directly, a nuance that has fueled great conflict about how the program works and should be regulated.

The Certified Pharmacy Benefits Specialist (CPBS) educational offering includes knowledge that is critical to effective management of the pharmacy and medical drug benefit. If you want to learn more, click here.

 News and notes from around the interweb:

• Drug Expenditure Dynamics 1995–2020

While the level of drug expenditure is closely watched and often commented upon, the composition of that expenditure and its dynamics are not as well understood. Typically, official statistics of drug spending only include drugs dispensed in pharmacies and do not include drugs used in hospitals, an issue which raises questions about their representativeness of total drug spending. In this report, for the first time, we have included estimates of total drug spending, including hospitals and net of discounts and rebates. These estimates have been based on official statistics from government agencies in the countries where available, in some cases not previously published internationally.

• Employer strategies to manage costs for rare diseases. Specialty medications for costly diseases such as cystic fibrosis, hemophilia, rheumatoid arthritis, and multiple sclerosis account for close to 50% of the total drug spend in America. While medications for these rare diseases can have a significant impact on health outcomes and improved quality of life, they often come at a steep price for employers. With growing concerns about the rising costs, employers need to have strategies in place to manage.

 News and notes from around the interweb:

• Employer strategies to manage costs for rare diseases. Specialty medications for costly diseases such as cystic fibrosis, hemophilia, rheumatoid arthritis, and multiple sclerosis account for close to 50% of the total drug spend in America. While medications for these rare diseases can have a significant impact on health outcomes and improved quality of life, they often come at a steep price for employers. With growing concerns about the rising costs, employers need to have strategies in place to manage.

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  An inflection point for biosimilars. Biosimilars continue to post monumental growth. Estimates suggest that global sales topped $15 billion in 2020, representing a compound annual growth rate of 56 percent since 2015 (Exhibit 1). The future looks equally bright, with a number of factors supporting continuing high growth.

• An attorney shares the warning signs of ‘self-serving’ PBMs. PBMs are designed to manage prescription drug benefits on the behalf of health insurers, saving both insurers and consumers money on prescription drugs. However, as the pharmaceutical industry has ballooned and drug prices have increased 33% since 2014, questions have been raised over whether PBMs are acting in the interest of their clients.
  

• Simplifying the Complexity of Value-Based Contracting: Present, Future Implications in Specialty Pharmacy. From a pharmaceutical perspective, these agreements come with risk, but they also serve as an opportunity to get either preferred product placement or to differentiate one’s product from the competition. Manufacturers can also address often burdensome prior authorizations with these products.

• Drug price reform: Time for employers to take action. A growing chorus of reform advocates is calling on plan sponsors to stop relying on legislative solutions that may never happen. Instead, they are encouraging employers to rise up and fight their own battles with the drugmakers, distributors and pharmacy benefit managers. Federal reforms will never “fix” the flaws of the pharmaceutical drug system; instead, sponsors need to flex their clout, and begin to take full advantage of the power they already possess.

 News and notes from around the interweb:

• Just because a drug is approved by the FDA, does not mean it has proof of efficacy. Medicare spent nearly $600 million over a three-year period to pay for cancer care involving four drugs later found to provide no clinical benefit for some forms of the disease for which the Food and Drug Administration approved them, an analysis published Monday, October 18, 2021 by JAMA Internal Medicine found.

• An attorney shares the warning signs of ‘self-serving’ PBMs. PBMs are designed to manage prescription drug benefits on the behalf of health insurers, saving both insurers and consumers money on prescription drugs. However, as the pharmaceutical industry has ballooned and drug prices have increased 33% since 2014, questions have been raised over whether PBMs are acting in the interest of their clients.
  

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  Large Private Employer Coalition Creates Pharmacy Benefit Management Firm. A nonprofit coalition of nearly 40 private employers, including U.S. retailers Walmart and Costco, has launched a new company that would offer pharmacy benefit management (PBM) services for employers.

• How PBM “rebate walls” impact drug spending, patient care and competition. Federal agencies and plan sponsors—the clients of PBMs—are beginning to explore perverse PBM incentives and are waking up to abusive PBM practices.

• Strategies for Aligning and Integrating Infusion Services Across the Health System. Nancy Palamara, PharmD, the vice president for diagnostics and therapeutics at Holy Name Medical Center, in Teaneck, N.J., polled session attendees as to who at their institution has operational oversight of the outpatient infusion center and all of its staff. The most common response was a nurse manager (35%), followed by a nonclinical manager (15%), pharmacist (4%) and physician (2%); 31% of respondents said oversight was handled by a mix of those roles, while 13% did not know.

 News and notes from around the interweb:

• An attorney shares the warning signs of ‘self-serving’ PBMs. PBMs are designed to manage prescription drug benefits on the behalf of health insurers, saving both insurers and consumers money on prescription drugs. However, as the pharmaceutical industry has ballooned and drug prices have increased 33% since 2014, questions have been raised over whether PBMs are acting in the interest of their clients.

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  White Bagging Update: PBMs’ Specialty Pharmacies Keep Gaining on Buy-and-Bill Oncology Channels. White bagging can boost profits and revenues for PBM-owned specialty pharmacies while increasing payers’ control over hard-to-manage medical benefit drugs. Hospitals, however, lose profits and face higher costs.

• How PBM “rebate walls” impact drug spending, patient care and competition. Federal agencies and plan sponsors—the clients of PBMs—are beginning to explore perverse PBM incentives and are waking up to abusive PBM practices.

• Walmart Increases Self-Funded Employer Access to Cost-Effective Care. Self-funded employer health plans will have access to Walmart’s collection of healthcare services following a partnership between the retail giant and a digital healthcare platform.

• Average Specialty Drug Price Reached $84,442 in 2020, Rising More Than Three Times Faster Than the Prices of Other Goods and Services. Retail prices for 180 widely used specialty prescription drugs increased by an average of 4.8% in 2020, more than three times the rate of general inflation for that same period (1.3%), according to AARP’s latest Rx Price Watch Report. This category generally includes drugs that are used to treat complex, chronic conditions and require special administration or handling.

 News and notes from around the interweb:

• White Bagging Update: PBMs’ Specialty Pharmacies Keep Gaining on Buy-and-Bill Oncology Channels. White bagging can boost profits and revenues for PBM-owned specialty pharmacies while increasing payers’ control over hard-to-manage medical benefit drugs. Hospitals, however, lose profits and face higher costs.

• How PBM “rebate walls” impact drug spending, patient care and competition. Federal agencies and plan sponsors—the clients of PBMs—are beginning to explore perverse PBM incentives and are waking up to abusive PBM practices.

• Increasing Patient Adherence to Oral Chemo. With more than 115 oral agents approved by the FDA to manage different types of cancer, oral oncolytics “have solidified their place in cancer treatment,” a pharmacist said at the virtual 2021 ASHP Specialty Pharmacy Conference.

• Average Specialty Drug Price Reached $84,442 in 2020, Rising More Than Three Times Faster Than the Prices of Other Goods and Services. Retail prices for 180 widely used specialty prescription drugs increased by an average of 4.8% in 2020, more than three times the rate of general inflation for that same period (1.3%), according to AARP’s latest Rx Price Watch Report. This category generally includes drugs that are used to treat complex, chronic conditions and require special administration or handling.

 News and notes from around the interweb:

• Kansas audited its $80 million CVS prescription plan, but it’s still shrouded in mystery. Kansas paid auditors $100,000 to dig into the more than $160 million it spent in 2018 and 2019 on prescription drugs for state employees, retirees and their families. But experts who follow the pharmaceutical industry say the resulting 16-page report doesn’t tell Kansas whether the health plan — or rather, the taxpayers and public employees who fund it — got a bargain or got gouged.

• How PBM “rebate walls” impact drug spending, patient care and competition. Federal agencies and plan sponsors—the clients of PBMs—are beginning to explore perverse PBM incentives and are waking up to abusive PBM practices.

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  Increasing Patient Adherence to Oral Chemo. With more than 115 oral agents approved by the FDA to manage different types of cancer, oral oncolytics “have solidified their place in cancer treatment,” a pharmacist said at the virtual 2021 ASHP Specialty Pharmacy Conference.

• Average Specialty Drug Price Reached $84,442 in 2020, Rising More Than Three Times Faster Than the Prices of Other Goods and Services. Retail prices for 180 widely used specialty prescription drugs increased by an average of 4.8% in 2020, more than three times the rate of general inflation for that same period (1.3%), according to AARP’s latest Rx Price Watch Report. This category generally includes drugs that are used to treat complex, chronic conditions and require special administration or handling. 

• PBM Settles Two Pharmacy Benefit Probes for $71 Million. The settlements, announced on Thursday in statements from the attorneys general in Illinois and Arkansas, are related to claims the pharmacy benefit management business inflated drug costs. The company has resolved similar disputes with Ohio and Mississippi and has reserved $1.1 billion to cover the claims.