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![CASE STUDY
Critics Proven Wrong on Hepatitis C Medicine Spending
What payers claimed would happen
“[I]t forces payers…to consider whether or not they
can even sustain the pharmacy benefit they provide
to members.”
– EXPRESS SCRIPTS (OCTOBER 2014)
“What they have done with this particular drug will break
the country…It will make pharmacy benefits no longer
sustainable. Companies just aren’t going to be able to
handle paying for this drug.”
– EXPRESS SCRIPTS (APRIL 2014)
“Never before has a drug been priced this high to treat a
patient population this large, and the resulting costs will
be unsustainable for our country. The burden will fall
upon individual patients, state and federal governments,
and payers who will have to balance access and
affordability in a way they never have had to before.”
– EXPRESS SCRIPTS (APRIL 2014)
What actually happened
“Hepatitis C is the first example where price is lower in the
U.S. vs. Western Europe because of our negotiations.”
– EXPRESS SCRIPTS (DECEMBER 2015)
“The price is sufficiently low that we can go to our clients
and say that they can treat every patient with hepatitis C.”
– EXPRESS SCRIPTS (JANUARY 2015)
“Our clients will save more than $1 billion this year on
hepatitis C medications, and we will financially guarantee
that their patients will adhere to their therapy.”
– EXPRESS SCRIPTS (JANUARY 2015)
“After our deal, other payers have begun to follow suit and
negotiate their own arrangements with either AbbVie or
Gilead. Because of our initial action, these follow-up
negotiations will ultimately lower the national spend on
hepatitis C drugs by more than $4 billion annually.”
– EXPRESS SCRIPTS (JANUARY 2015)](https://image.slidesharecdn.com/prescriptionmedicines-costsincontext-151111184633-lva1-app6891/75/Prescription-Medicines-Costs-in-Context-17-2048.jpg)
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Prescription Medicines: Costs in Context
This document summarizes information about prescription drug costs and development. It discusses how medicines have transformed treatment for diseases like hepatitis C and cancer. Developing new treatments takes over 10 years and $2.6 billion on average, with only 12% of drug candidates being approved. Medicines help avoid expensive medical services and provide major savings to the healthcare system. While drug costs have risen, they account for a stable share of overall healthcare spending and are projected to grow in line with other healthcare costs. Many factors influence drug prices, including discounts, rebates, and competition from generics.
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Prescription Medicines: Costs in Context
- 1. Prescription Medicines: Costs inContext Updated August 2016
- 2. Medicines Benefit Patients,the Health Care System and the Economy
- 3. Medicines are Transformingthe Treatment OF DEVASTATING DISEASES HEPATITIS C The leading cause of liver transplants and the reason liver cancer is on the rise – is now curable in more than 90 percent of treated patients.* CANCER New therapies have contributed to a 23% decline in the cancer death rate since its peak in 1991. Today, 2 out of 3 people diagnosed with cancer survive at least 5 years.** HIGH CHOLESTEROL America’s biopharmaceutical companies are currently developing 190 medicines to treat heart disease, stroke and other cardiovascular diseases. New PCSK9 inhibitors have revolutionized high cholesterol treatment. Between 1991 and 2011, the death rate from heart disease dropped 46%.*** Gov. Hogan’s Cancer is in Remission, 30 Days After He Completed Chemo Former President Jimmy Carter Says He is Free of Cancer November 16, 2015 December 6, 2015
- 4. MORE THAN 7,000MEDICINES ARE IN DEVELOPMENT Around the World NOTE: Each product is counted exactly once, regardless of the number of indications pursued. MEDICINES IN DEVELOPMENT
- 5. Developing New Treatmentsand Cures IS A COMPLEX AND RISKY UNDERTAKING On average, it takes more than 10 years and $2.6B to research and develop a new medicine.* BETWEEN 1998 AND 2014 Unsuccessful Attempts Successful Attempts 123 Alzheimer’s Disease** 96 Melanoma*** 167 Lung Cancer*** 4 Alzheimer’s Disease 7 Melanoma 10 Lung Cancer Just 12% of drug candidates that enter clinical testing are approved for use by patients
- 6. Medicines Help Patients AVOIDEXPENSIVE HOSPITAL SERVICES The U.S. health care system could save $213 billion annually if medicines were used properly* Adherence to Medicines Lowers Total Health Spending for Chronically Ill Patients**
- 7. MEDICINES PROVIDE CRITICALSAVINGS to the U.S. Health Care System Estimated 10-Year savings to Medicare from improved adherence to congestive heart failure medications, 2013-2022* $22.4 billion Costs avoided by 2050 if we develop a new medicine that delays the onset of Alzheimer’s disease by just five years** $367 billion
- 8. CASE STUDY As HIV/AIDSTreatment Improved SPENDING BECAME SUSTAINABLE
- 9. The Biopharmaceutical Sectoris the SINGLE LARGEST FUNDER OF BUSINESS R&D IN THE UNITED STATES
- 10. The Biopharmaceutical Industry’s IMPACTON THE U.S. ECONOMY Nearly 4.5 Million Jobs ECONOMIC OUTPUT FROM INDUSTRY $1.2 Trillion Nearly $311 Billion paid in wages and benefits Annual average compensation of $123,108 IN DIRECT JOBS is more than twice the average annual salary for all other jobs.
- 11. Prescription Drug Costsin Perspective
- 12. Medicines Account fora STABLE SHARE OF HEALTH CARE SPENDING
- 13. Federal Government Projects MEDICINESPENDING WILL GROW IN LINE WITH HEALTH SPENDING
- 14. GROWTH IN OTHERHEALTH CARE SERVICES WILL BE FIVE TIMES Total Medicine Spending Growth Through Next Decade Projected Annual Growth in Spending ($ Billions) (10-year cumulative increase: $2,044 billion) (10-year cumulative increase: $390 billion)
- 15. BRAND MEDICINE NETPRICE GROWTH SLOWED IN 2015 as Discounts, Rebates Negotiated by Payers Rose Sharply
- 16. POWERFUL PURCHASERS NEGOTIATEDRUG PRICES Negotiating power is increasingly concentrated among fewer pharmacy benefit managers (PBMs), with the TOP THREE PBMS ACCOUNTING FOR THREE QUARTERS OF THE MARKET.
- 17. CASE STUDY Critics ProvenWrong on Hepatitis C Medicine Spending What payers claimed would happen “[I]t forces payers…to consider whether or not they can even sustain the pharmacy benefit they provide to members.” – EXPRESS SCRIPTS (OCTOBER 2014) “What they have done with this particular drug will break the country…It will make pharmacy benefits no longer sustainable. Companies just aren’t going to be able to handle paying for this drug.” – EXPRESS SCRIPTS (APRIL 2014) “Never before has a drug been priced this high to treat a patient population this large, and the resulting costs will be unsustainable for our country. The burden will fall upon individual patients, state and federal governments, and payers who will have to balance access and affordability in a way they never have had to before.” – EXPRESS SCRIPTS (APRIL 2014) What actually happened “Hepatitis C is the first example where price is lower in the U.S. vs. Western Europe because of our negotiations.” – EXPRESS SCRIPTS (DECEMBER 2015) “The price is sufficiently low that we can go to our clients and say that they can treat every patient with hepatitis C.” – EXPRESS SCRIPTS (JANUARY 2015) “Our clients will save more than $1 billion this year on hepatitis C medications, and we will financially guarantee that their patients will adhere to their therapy.” – EXPRESS SCRIPTS (JANUARY 2015) “After our deal, other payers have begun to follow suit and negotiate their own arrangements with either AbbVie or Gilead. Because of our initial action, these follow-up negotiations will ultimately lower the national spend on hepatitis C drugs by more than $4 billion annually.” – EXPRESS SCRIPTS (JANUARY 2015)
- 18. CASE STUDY Critics ProvenWrong on High Cholesterol Medicine Spending What payers claimed would happen “These drugs are not only expensive but they present a financial challenge to the health care industry.” – HARVARD PILGRIM HEALTH CARE (SEPTEMBER 2015) “While these drugs are being viewed as breakthroughs, they also have the potential to wreck financial havoc on clients who do not proactively manage.” – EXPRESS SCRIPTS (JULY 2015) “Given the number of people potentially eligible for treatment with PCSK9 will number in the millions, the potential overall expenditures by payers are huge.” – CVS HEALTH (JULY 2015) What actually happened “We are in a situation where we can bargain with the drug manufacturers to get a significant discount in return for an exclusive deal.” – CVS HEALTH (NOVEMBER 2015) “We were able over the course of tough negotiations to get good economics on both products.” – EXPRESS SCRIPTS (OCTOBER 2015) “We feel very confident we can manage this and this won’t mess up our clients’ budgets in 2016.” – EXPRESS SCRIPTS (OCTOBER 2015)
- 19. Insurers’ Data Show MEDICINESARE NOT MAIN DRIVER OF PREMIUM INCREASES Average Dollar Increase in Monthly Premium by Category, 2016 Individual and Small Group Plans “Pharmaceutical expenses may be the factor most open to exploitation by health plans searching for a Trojan horse with which to usher in excessively priced insurance rates.” —Consumers Union in San Francisco
- 20. Nearly 9 Outof Every 10 U.S. Prescriptions ARE FILLED WITH GENERICS
- 21. Medical Procedures BecomeMore Expensive Over Time, BUT COST CONTAINMENT IS BUILT INTO MEDICINE LIFE CYCLE
- 22. Example THEN & NOW HowPrescription Drug Prices Fall Significantly Over Time
- 23. $93 BILLION OFU.S. BRAND SALES are Projected to Face Generic Competition
- 24. Changes in thePrescription Medicine Marketplace: Challenges and Opportunities
- 25. Economics of MedicinesHave CHANGED MARKEDLY IN RECENT YEARS THE SCIENCE IS HARDER AND MORE COSTLY Researchers targeting more complex diseases Rise of personalized medicine Higher regulatory hurdles Longer, more complex clinical trials Genomics/molecular medicine are complex new frontiers Increased cost of R&D THE MARKET IS TOUGHER Slow uptake of new medicines/ rapid adoption of generics Eroding intellectual property (IP) protections Increased patient cost-sharing and coverage restrictions Providers increasingly accountable for cost of care Increase in required government rebates BIOPHARMACEUTICAL INNOVATION
- 26. 2 • Researchand Development Cost to Develop a New Medicine MORE THAN DOUBLED OVER PAST DECADE
- 27. INCREASING INTELLECTUAL PROPERTYTHREATS Cause Uncertainties and Costs for Biopharmaceutical Companies Intensified efforts to invalidate patents Continued efforts to reduce or eliminate data and market exclusivity Generic challenges to patents happening earlier and more frequently reducing patent life for innovator drugs ‘Patent Death Squads’ vs. Innovation The Patent Trial and Appeal Board was supposed to make the system better. It hasn’t. — By Peter J. Pitts June 10, 2015
- 28. 3 • MarketDynamics COMPANIES RACE TO BE FIRST TO MARKET with a New Medicine Competing brands generally launch within two years. Time Between Approval of First and Second Medicines in a Pharmacologic Class Has Declined Dramatically
- 29. 3 • MarketDynamics RAPID CHANGE IN THE MARKET for Medicines VALUE-BASED INSURANCE DESIGN CLINICAL PATHWAYS ACCOUNTABLE CARE ORGANIZATIONS PROVIDERS AT RISK FOR MEDICINE COSTS BUNDLED PAYMENTS OUTCOME-BASED ARRANGEMENTS VALUE ASSESSMENT FRAMEWORKS
- 30. 3 • MarketDynamics Increasing Provider Accountability for Cost of Care and Pathway Compliance is INFLUENCING PRESCRIBING DECISIONS THEN NOW Patients in health plans that incentivize providers to prescribe certain treatments* 37% 2014 88% 2016 (Projected) Hospital participation in accountable care organizations responsible for cost of care** 6% 2011 25% 2014 Medicare payments tied to alternative payment models which include cost or quality incentives*** 0% 2009 30% 2014 Commercial market payments where provider is at-risk for cost of care**** 6% 2013 21% 2014
- 31. 3 • MarketDynamics Medicines are Increasingly Put in the HIGHEST-COST TIER BY INSURANCE COMPANIES
- 32. 3 • MarketDynamics Share of Commercial Plans with a PRESCRIPTION DRUG DEDUCTIBLE IS INCREASING
- 33. Patient Assistance ProgramsCan Play an Important Role in MAINTAINING PATIENT ACCESS TO MEDICINES
- 34. PROMOTE VALUE-DRIVEN HEALTHCARE • Address barriers to paying for value, develop patient-centered value assessment tools and support appropriate use of medicines MODERNIZE THE DRUG DISCOVERY AND DEVELOPMENT PROCESS • Modernize the FDA to keep pace with scientific discovery and increase efficiency of generic approvals ENGAGE AND EMPOWER CONSUMERS • Make quality and cost information public to aid in decisions and enforce common-sense rules that prevent discrimination against vulnerable patients ADDRESS MARKET DISTORTIONS • Improve risk adjustment models and reform market distorting programs like the 340B Drug Pricing program PRAGMATIC SOLUTIONS to Address Cost Concerns