A recent article in MedPage - Insurers to CMS, Congress: For Lower Rx Costs, Hand Us the Reins – needs a bit of translation to help people under stand what handing insurers the rein over what drugs and how much to spend really means. For instance, the headline should actually read "Insurers to CMS, Congress: We Want More Rx Rebates So Give Us Total Control Over Medicare Drug Benefit"
According to Medpage: “Congress and the administration can help rein in rising drug costs through a few key regulatory and legal fixes, said insurers and pharmacists at AHIP's National Conference on Medicare, Medicaid and Duals on Tuesday.”
"I think plans need to be given a little bit more leeway to truly assess the value of drugs to make a decision: does this drug at the cost really provide any additional value?" said Sarah Marche, PharmD, vice president of pharmacy services at Highmark, a Blue Cross affiliate in Pennsylvania.
Translation: We already limit access to life saving medicines for the most chronically and seriously ill seniors based on our current value assessment. But we want even more control over what patients get. And by ‘additional value’ we mean increasing the 35-40 percent price discounts we get and what consumers are charged. We want more.
Marche noted that not every drug Medicare covers adds value.
"Glumetza [a branded version of metformin] provides no value above and beyond what's available, and if you look at a lot of the commercial formularies, it's blocked," she said. "Nobody's dying. Nobody has any huge issues with that, but we don't have that same flexibility within the Medicare space. So, you're covering a drug that really provides no additional value, just increasing the cost."
Translation: After Valeant got hammered for hiking Glumetza by more than 800% in 2015, the list price of stood at $10,020 for 90 tablets, up from $896 in January 2013,. For the longest time, insurers didn’t complain . Half of Glumetza’s price is given back in discounts, rebates, chargebacks, and the like to wholesalers, managed care organizations, pharmacy benefit managers, federal and state healthcare programs, and others.
Under pressure to reduce prices, Valeant gave Walgreens’s an exclusive deal to sell Glumetza as generic prices. So Express Scripts, the company running our drug benefit decided it could turned around an blocked Glumetza and cutting a deal with a company making a generic version of the drug to make up for the lost rebate revenue. So we would have covered it if had provided additional profit… I mean value to us regardless of cost. It really depends on the rebates Express Scripts can share with us.
Another panelist, Mark Owen, MBA, president of government programs for the the Blue Cross-affiliated Health Care Service Corp., power “to limit beneficiary access to specialty pharmacies.”
While Owen noted that critics of the idea have said such a change could pose access challenges, he argued that allowing plans to direct beneficiaries towards only certain pharmacies could lower costs and increase adherence.
Translation: Limiting access allows us to pocket more money because it ensures patients have no choice but to take the drugs that we give them. That way we make the biggest profit margin whether they like it or not. And we know that charging patients about 40 percent of the retail price of products is a good way to force them to use drugs what give us the biggest margin. We will work really hard to increase adherence, but only with drugs that fatten our bottom line regardless of whether the drug works for that patient or not.
According to Medpage: “Congress and the administration can help rein in rising drug costs through a few key regulatory and legal fixes, said insurers and pharmacists at AHIP's National Conference on Medicare, Medicaid and Duals on Tuesday.”
"I think plans need to be given a little bit more leeway to truly assess the value of drugs to make a decision: does this drug at the cost really provide any additional value?" said Sarah Marche, PharmD, vice president of pharmacy services at Highmark, a Blue Cross affiliate in Pennsylvania.
Translation: We already limit access to life saving medicines for the most chronically and seriously ill seniors based on our current value assessment. But we want even more control over what patients get. And by ‘additional value’ we mean increasing the 35-40 percent price discounts we get and what consumers are charged. We want more.
Marche noted that not every drug Medicare covers adds value.
"Glumetza [a branded version of metformin] provides no value above and beyond what's available, and if you look at a lot of the commercial formularies, it's blocked," she said. "Nobody's dying. Nobody has any huge issues with that, but we don't have that same flexibility within the Medicare space. So, you're covering a drug that really provides no additional value, just increasing the cost."
Translation: After Valeant got hammered for hiking Glumetza by more than 800% in 2015, the list price of stood at $10,020 for 90 tablets, up from $896 in January 2013,. For the longest time, insurers didn’t complain . Half of Glumetza’s price is given back in discounts, rebates, chargebacks, and the like to wholesalers, managed care organizations, pharmacy benefit managers, federal and state healthcare programs, and others.
Under pressure to reduce prices, Valeant gave Walgreens’s an exclusive deal to sell Glumetza as generic prices. So Express Scripts, the company running our drug benefit decided it could turned around an blocked Glumetza and cutting a deal with a company making a generic version of the drug to make up for the lost rebate revenue. So we would have covered it if had provided additional profit… I mean value to us regardless of cost. It really depends on the rebates Express Scripts can share with us.
Another panelist, Mark Owen, MBA, president of government programs for the the Blue Cross-affiliated Health Care Service Corp., power “to limit beneficiary access to specialty pharmacies.”
While Owen noted that critics of the idea have said such a change could pose access challenges, he argued that allowing plans to direct beneficiaries towards only certain pharmacies could lower costs and increase adherence.
Translation: Limiting access allows us to pocket more money because it ensures patients have no choice but to take the drugs that we give them. That way we make the biggest profit margin whether they like it or not. And we know that charging patients about 40 percent of the retail price of products is a good way to force them to use drugs what give us the biggest margin. We will work really hard to increase adherence, but only with drugs that fatten our bottom line regardless of whether the drug works for that patient or not.
