Keep an Eye on the PBM Angle of the Would-Be Cigna-Humana Merger

It’s World AIDS Day today. This used to be a much high-profile event, with consistent media coverage. That’s changed, slowly, over the two decades or so, which — I fear — is a sign that the public at large is losing perspective on the continued battle against HIV and AIDS. 

So it’s worth taking a moment to pause today and consider the ongoing efforts. If you’re looking for a starting point, PhRMA has an excellent blog post and video on how industry has been targeting the problem.

I missed yesterday, so it ought not be news to you all that Cigna and Humana are exploring a merger. The Sparknotes version is that this would be a chocolate-and-peanut-butter combination of Cigna’s commercial business and Humana’s strength in Medicare plans. 

WSJ had the scoop, and if you want to go right to the source, here is the initial coverage (gift link). 

But over the past day or so, there’s been a lot more commentary on another angle on the deal: both Cigna (Express Scripts) and Humana have PBMs. And there are a ton of people who really don’t like the idea of the big PBMs garnering any more power. So there’s already a number of voices wondering whether PBM-related skepticism will kill the deal. WSJ’s David Wainer may have the best take on that subject (another gift link). 

I’m no expert on M&A or antitrust enforcement, but it would be a lot of fun if the FTC tried to get Cigna to spin off Express Scripts as a condition of the deal. Cigna would never do that, of course, but it would still be entertaining to see it go down.

This is a really smart USA Today piece about the fact that a lot of Medicare plans are dropping certain insulin brands as a way to control costs in the face of some IRA-related changes (particularly the $35 copay cap). The article is positioned as service journalism, but it should be considered a real-world example of how the IRA is going to have predictable (if unintended) negative impacts on access for patients. 

The government filed its final brief in Merck’s lawsuit over the IRA. The next step, then, is an oral argument. It’ll be the first time a full suit goes in front of a judge and marks a milestone in the progression of the legal battles against the law. (Weirdly, I haven’t seen any coverage.)

As you all know, I love a good rant here. And this missive, from Peter Kolchinsky on the battle against hepatitis C is Egypt, is a great one. 

I wrote earlier in the week about the Biden administration’s decision to fight an anti-copay-accumulator legal decision, but it’s an issue that’s being kept in the public eye. The All Copays Count coalition has their own release on the current state of play there. And if the members of that group start making a racket, the government’s decision will remain front and center for the foreseeable future. 

PCMA leader JC Scott has an op-ed defending PBMs from regulation, leaning into the role of the PBMs in keeping premiums down. Not sure there’s anything novel, but keeping up with the PBM industry’s messaging is always constructive. 

My impression is that this (failed) legislative effort to require DTC ads to include list prices is mostly political theater, but it’s a reminder that the subject of DTC ads makes for pretty good theater. 

Tufts held an enlightening webinar this week on “US payer coverage of specialty drugs: Outlook for 2024.” The slides are here. 

ICER’s out with the draft evidence report for the Karuna schizophrenia med, which is due for FDA action next September. It looks like the drug is bumping right up against ICER’s definition of cost-effectiveness, which means that the final verdict here is probably going to depend a lot on the actual net price. But this is a case where the math probably doesn’t capture the whole picture. We’re talking about a new class of medicine in an area of continuing unmet need. This is exactly the kind of innovation we want to encourage, so making the discussion narrowly about cost-effectiveness probably misses part of the point.