Category: Benefit Design

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Benefit Design, Costs/Reimbursement, Gross-to-Net Bubble, Health Care Policy, Industry Trends, Medicare Part D, PBMs

Six Reasons Why the Rebate Rule Failed—And What’s Next

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Yesterday, we all awoke to the unexpected news that the Department of Health & Human Services (HHS) withdrew its plans to reform rebates in federal programs. The world without rebates has been delayed—perhaps indefinitely. Below, I highlight six key policy and political factors behind this decision. I also discuss winners and losers among drug channel participants. The underlying problems of the the gross-to-net bubble remain. As H.L. Mencken observed: “There is always a well-known solution to every human problem—neat, plausible, and wrong.” Get ready for a slew of drug pricing policy proposals that perfectly fit these criteria. Read more » … Continue reading Six Reasons Why the Rebate Rule Failed—And What’s Next

Benefit Design, Costs/Reimbursement, Gross-to-Net Bubble, Health Care Policy, Industry Trends, PBMs

The Gross-to-Net Bubble Reached a Record $166 Billion in 2018 (rerun)

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This morning, the White House withdrew its proposed rule to reform the rebate system in federal programs. I am surprised by the timing, which likely has more to do with politics than policy. Tomorrow, I’ll post some reflections on this unexpected news.  In the meantime, today’s rerun is a reminder of what’s still at stake in reforming rebates within the U.S. drug channel .  Click here to see the original post and comments from April 2019. You can also reach this post at www.GrossToNetBubble.com. 😉 The gross-to-net bubble—the ever-growing pile of money that sits between a manufacturer’s list price for a drug and … Continue reading The Gross-to-Net Bubble Reached a Record $166 Billion in 2018 (rerun)

Benefit Design, Costs/Reimbursement, Gross-to-Net Bubble, PBMs, Specialty Drugs

How Health Plans Profit—and Patients Lose—From Highly-Rebated Brand-Name Drugs (rerun)

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This week, I’m rerunning some popular posts during the holiday week. Click here to see the original post and comments from February 2019. My Wall Street Journal op-ed (Don’t Blame Drug Prices on ‘Big Pharma’) has received a lot of attention. Especially notable was a letter to the editor from American Health Insurance Plans (AHIP). It claims that “the savings that insurance providers negotiate are returned directly to consumers through lower premiums and out-of-pocket costs.” Don’t believe this misleading half-truth. It distorts the primary argument of my WSJ op-ed: Patients often pay full price for drugs that are sold to insurers … Continue reading How Health Plans Profit—and Patients Lose—From Highly-Rebated Brand-Name Drugs (rerun)

Benefit Design, Costs/Reimbursement, Gross-to-Net Bubble, Health Care Policy, Medicare Part D, PBMs, Pharmacy

Drug Channels News Roundup, June 2019: PBM Spread Pricing, Rebate Walls, Reforming Part D, and Not-So-Smart Bulbs

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Happy 243rd birthday, America! Before you launch your July 4 festivities, Drug Channels offers some fireworks of its own: Surprising PBM spread pricing profits in Massachusetts plans Eli Lilly explains rebate walls for specialty drugs MedPAC suggests Part D changes—and endorses a well-known Drug Channels term! Plus, the funniest video that I have ever seen. P.S. @DrugChannels on Twitter now has more than 7,700 followers. See why by following my daily musings and cool links. Read more » Copyright © 2006-2019 Pembroke Consulting, Inc. d/b/a Drug Channels Institute. Drug Channels® is a registered trademark of Pembroke Consulting, Inc. This Feed … Continue reading Drug Channels News Roundup, June 2019: PBM Spread Pricing, Rebate Walls, Reforming Part D, and Not-So-Smart Bulbs

Benefit Design, Costs/Reimbursement, Generic Drugs, Industry Trends, PBMs, Specialty Drugs

Which PBM Best Managed Drug Spending in 2018: CVS Health, Express Scripts, MedImpact, or Prime Therapeutics?

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It’s time for our annual Drug Channels’ examination of drug spending reports. For 2018, we again aim our magnifying glass at the annual trend reports from four large pharmacy benefit managers (PBMs): CVS Health, Express Scripts, MedImpact, and Prime Therapeutics. (See their report links below.) The other large PBMs—Humana and OptumRx (UnitedHealth)—provide no public transparency into their performance. Using these data, which account for most of the commercial market, we detect the following key trends for 2018: Once again, we find that drug spending is not skyrocketing—contrary to what you often hear from journalists and politicians. Spending grew by about … Continue reading Which PBM Best Managed Drug Spending in 2018: CVS Health, Express Scripts, MedImpact, or Prime Therapeutics?

Benefit Design, Costs/Reimbursement, Gross-to-Net Bubble, PBMs, Specialty Drugs

Express Scripts Launches a New Formulary for a World Without Rebates. Will Plan Sponsors and Drug Makers Play Along? (rerun)

Admin

This week, I’m rerunning some popular posts while I attend Asembia’s 2019 Specialty Pharmacy Summit. This is an especially timely rerun. Believe it or not, Express Scripts’ 2019 formulary prefers Eli Lilly’s high-list/high-rebate Humalog insulin over the authorized generic version that is being sold at a 50% lower list price. The authorized generic will be preferred only on Express Scripts’ Flex Formulary, which has very low adoption.  Bottom line: Many plans still crave rebate dollars. Sorry, patients with deductibles and coinsurance. The gross-to-net bubble lives on!  Click here to see the original post and comments from November 2018. Express Scripts has … Continue reading Express Scripts Launches a New Formulary for a World Without Rebates. Will Plan Sponsors and Drug Makers Play Along? (rerun)

Benefit Design, Costs/Reimbursement, Gross-to-Net Bubble, Health Care Policy, Industry Trends, PBMs

My Wall Street Journal Op-Ed: Don’t Blame Drug Prices on ‘Big Pharma’ (rerun)

Admin

This week, I’m rerunning some popular posts while I attend Asembia’s 2019 Specialty Pharmacy Summit. Click here to see the original post and comments from February 2019. Yesterday, The Wall Street Journal published my op-ed: Don’t Blame Drug Prices on ‘Big Pharma’. The article text is pasted below for those who don’t subscribe. I wrote this piece for a general business audience, though my arguments about rebates and patient out-of-pocket costs will be familiar to regular readers of Drug Channels. Alas, I had to omit such insider terms as gross-to-net bubble, direct and indirect remuneration, and SpongeBob SquarePants. A personal … Continue reading My Wall Street Journal Op-Ed: Don’t Blame Drug Prices on ‘Big Pharma’ (rerun)

Benefit Design, Costs/Reimbursement, Gross-to-Net Bubble, Health Care Policy, Industry Trends, PBMs

The Gross-to-Net Bubble Reached a Record $166 Billion in 2018

Admin

The gross-to-net bubble—the ever-growing pile of money that sits between a manufacturer’s list price for a drug and the net price after rebates and other reductions—reached another high last year. Drug Channels Institute developed the term gross-to-net bubble to describe the speed and size of growth in the total value of manufacturers’ gross-to-net reductions. We estimate that in 2018, the total value of gross-to-net reductions for brand-name drugs was $166 billion. As you will see below, that figure doubled over the preceding six years. Below, I also highlight the various elements that fill the bubble. About two-thirds of total gross-to-net … Continue reading The Gross-to-Net Bubble Reached a Record $166 Billion in 2018

340B, Benefit Design, Costs/Reimbursement, Health Care Policy, PBMs

Drug Channels News Roundup, March 2019: The Insulin Gross-to-Net Bubble, HHS Blasts Rebates, a New 340B Report, and Theranos

Admin

Spring has finally reached our worldwide headquarters here in lovely downtown Philadelphia. (See photo at right.) Before your allergies kick in, please inhale this month’s selection of noteworthy news stories: Eli Lilly discloses the bonkers gross-to-net economics for Humalog insulin John O’Brien of HHS blasts the current drug pricing system The Community Access National Network’s 340B Commission releases an excellent new report—and you can read my testimony, too! Plus, a compelling new HBO documentary delves further into the sordid tale of Elizabeth Holmes and Theranos. P.S. Join the more than 7,200 people who follow my comments and links at @DrugChannels … Continue reading Drug Channels News Roundup, March 2019: The Insulin Gross-to-Net Bubble, HHS Blasts Rebates, a New 340B Report, and Theranos

Benefit Design, biosimilars, Channel Management, Costs/Reimbursement, Health Care Policy, Medicare Part D, PBMs

A World Without Rebates: Predictions for How the Channel Will Evolve and Why Drug Prices Will Go Down

Admin

Two years ago on Drug Channels, I wrote about a shift from rebates to discounts as a black swan event—a massively important yet unexpected break from current practice. Given recent developments, I believe that we are moving ever closer to a world without rebates. Yet there are many unanswered questions were such a radical shift to occur. As I see it, a world without rebates would force manufacturers to use net price as a competitive weapon. If PBMs and payers behave logically, then drug prices would drop as manufacturers are forced to compete more aggressively for prescriptions. These conclusions are … Continue reading A World Without Rebates: Predictions for How the Channel Will Evolve and Why Drug Prices Will Go Down