With the pervasive entry of copay accumulator programs, patients find themselves, yet again, pawns in the pricing battle between payers and pharma. This shift in benefit design disrupts the conventional allocation of copay assistance toward the patient’s deductible, forcing a greater share of drug cost onto patients. Though on its surface a strictly cost-savings move, the human cost of the copay accumulator will ripple through patient populations, leaving disruptions of care in its wake. As these programs gain traction, payers, pharma, and patients will all feel their impact.
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The PharmD Corner
Biosimilars are supposed to save us money, but whose money are they saving?
Recent updates to the Medicare reimbursement policies, the passage of the president’s Bipartisan Budget Act of 2018, and analyses of these changes from various consultants have unveiled the chaos that is biosimilar reimbursement.
Amid heightened focus on prescription drug prices and slow progress from Congress, states are taking matters into their own hands.
California is the prime example. Gov. Jerry Brown, a Democrat, signed SB 17 into law early last month. The law requires drug makers to report price hikes that accumulate to 16% over three years at least 60 days before the increase and provide justification for it.
Back in the 20th century, many physicians conducted home visits. Whether it was for a serious illness or a minor problem like a common cold, patients had access to doctors without leaving their homes.
With prices hitting new highs, payers are more interested than ever in seeing evidence that the drugs they pay for will perform as well as they did in clinical trials. They’re also looking at outcomes beyond narrow clinical endpoints such as blood pressure and placing emphasis on improvements in quality of life. And, as the ones footing the bill for expensive medications, payers also have a strong interest in keeping costs under control. They’re not alone.
In a time of deep partisan division, the 21st Century Cures Act stands out as an exception to the rule. The law passed late last year with broad support from both Democrats and Republicans and was signed into law by former President Obama.
The Cures Act is intended to modernize and accelerate medical product discovery, development, and delivery. It will change the FDA drug approval process in important ways, and those provisions have—understandably—gotten most of the attention.
A few weeks ago, the U.S. Department of Health and Human Services made a final rule on a policy that implemented incentive payment provisions in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). This rule, which takes effect January 2017, has huge potential to change the health care market.
You’ve all seen the headlines and statistics:
“Drug overdose deaths have now surpassed fatal car accidents, with more than 47,00 lethal overdoses in 2014.”
“In 2012, 259 million prescriptions were written for opioids, which is more than enough to give every American adult their own bottle of narcotics.”
The 340B Program has evolved into a source of major profit for some covered entities. Pharmaceutical manufacturers know this, but do payers?
Kayenta Health Center is a plain, white concrete building next to a grid of trailers that house the health care staff. The one-story hospital is on an isolated Native American reservation in Northern Arizona, an hour’s drive away from the Four Corners and more than two hours from the nearest major city. This was my home for five weeks as a pharmacy rotation student.
According to the Express Scripts 2015 Drug Trend Report, inflammatory conditions made up the top specialty therapy class when ranked by per-member, per-year spend, with an average cost per prescription of $3,035.96. The category saw a 17% increase in unit costs for the top two products by utilization, Enbrel and Humira Pen.
In a bold attempt to leverage various alternative payment model initiatives to move 50% of Medicare payments into alternatives to fee for service by 2018, CMS plans to launch the largest-ever multi-payer program to improve the quality of primary care. The initiative, called the Comprehensive Primary Care Plus (CPC+) program, is scheduled to start next year and builds on CMS’ Comprehensive Primary Care (CPC) initiative, which started in 2012 and will end this year.
In today’s society, patience is a lost virtue. Americans do not want to wait and expect everything “now,” from social media updates to products being delivered the same day they are ordered.
The aggressive shift from volume to value has all stakeholders—payers, providers, and pharma—considering what they can do to stay relevant.
Alternatives to the traditional fee-fee-service are becoming increasingly, but perhaps nowhere is the shift from volume to value gaining more traction that in oncology. No doubt the expense of cancer care has something to do with that. A study that linked Medicare records with survival and incidence data from the Survival, Epidemiology, and End Results (SEER) database estimated that the medical costs of cancer care in the U.S.
Two hundred seventy provider-sponsored plans (PSPs), in which health systems and insurers join forces to create an integrated model, are in operation today—up from 107 just two years ago. More and more PSPs continue to outperform their competitors as they have learned the hard lessons from the late 1990s, when many providers entered and exited the PSP business often with sizable and embarrassing losses.
With approximately $5 billion worth of state cuts in mental services from 2009 to 2012, the elimination of nearly 4,500 public psychiatric beds during the same time period, and a shortage of behavioral health providers, it is no surprise that many Americans with serious mental illness aren’t getting the care they need.
They aren’t just falling through cracks here and there; they’re tumbling through gaping holes in system that’s broken.