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Look, fish got to swim, birds got to fly. And every piece of the health care system needs to emphasize the benefits they bring to the table. So I will throw no shade on the strategy of PCMA working to sell in the benefits of PBMs to employers.
I won’t throw shade on the strategy, but I will throw a little shade on the execution. The two CEO interviews featured as a part of the campaign seem to show employers who are under-informed, relying on PBMs to keep them educated.
And there are some weird lines in there, like the guy who calls the PBM part of the “family”. He’s the one who talked about how the company has weathered employees with open heart surgery and 12 childbirths … which are not the expenses that PBMs are really impacting.
The other guy said that an inability to use spread pricing would be a “disincentive to even start a company,” which is, um, pretty hyperbolic.
Honestly, I’m not the best person to make that case. Mark Cuban is. So I’ve tagged Mark on LinkedIn in hopes that he can take it from here …
Yesterday, I provided my list of the 15 medicines** that I think will make the next round of price controls, which surfaces a number of worthwhile questions:
What will the government do with Ozempic/Wegovy’s price? The temptation for political meddling here must be enormous. On the other hand, the value that those medicines are going to be able to demonstrate is pretty amazing.
Does experience matter? This won’t be Novo’s first rodeo, nor will AbbVie — which may have two meds on the list — be new to the process. Does this give them an advantage over GSK or Astellas, which are both likely to see the IRA spotlight hit them for the first time?
How will patients respond? The first group of price-controlled meds was most concentrated in a couple of therapeutic areas (diabetes and heart disease). The next group will span a larger group of diseases, making me wonder how advocates looking at this for the first time will react.
Will the practice of cutting list prices (but not necessarily net prices) enter the discussion? My math suggests that a lot of inhalers that are taking big list-price decreases will end up seeing gross spending in Medicare drop enough to take them off the list. I’m wondering if that phenomenon will get any attention.
Does this mean more lawsuits? Implementation is going to be different for every drug, so even if the big constitutional questions get answered, there’s still room for legal wrangling.
Is this it for Part D drama? After the 2027 cohort, there aren’t many meaningful Part D medicines left to price control. Yes, some bigger names will see their number come up in future years, but the pickings get pretty slim from here on out.
How will oncology meds be handled? In the first cycle, only one oncology med made the list (Ibruvica), and it’s not clear that the med is a particularly good analogue for the cancer meds in the second cycle.
What of Part B? The last question segues to this one. It’s pretty clear that the initial group of price-controlled medicines are largely highly rebated products that shed little light on how the government will think about little-rebated Part B meds (which enter the IRA meat grinder as a part of the 2028 cycle, which starts in 2026). Will this next group of medicines provide a roadmap for how the government will evolve its approach?
** William Feldman at Harvard PORTAL suggested to me on LinkedIn that Invega, one of the meds on my list, would be considered a generic and not selected. So I’m already having to update and revise. Let’s say, in the absence of a more thoughtful analysis, that Invega is out and Lenvima is in.
Earlier in the week, commenting on this illuminating WSJ piece on the burden of cancer-related costs, I mentioned that the story did not look at “whether more thoughtful use of 340B dollars could ameliorate any issues.”
It was kind of a throwaway line, a shallow reminder that hospitals — the source of much of the financial hardship faced by cancer patients — have at their disposal a 340B-derived source of revenue that could be used to help alleviate financial pressures faced by those with cancer.
And then I saw this publication in the journal Cancer — “Addressing financial toxicity in cancer treatment — An opportunity for the 340B drug pricing program” — which makes concrete what I only hinted at.
It’s a reminder that doctors, too, are looking toward the 340B program as a solution to specific issues for low-income Americans, rather than an accountability-less wealth transfer to hospitals.
KHN Health News has a great piece describing how rural hospitals are refusing to become “rural emergency hospitals,” even though the communities need emergency services and even though such facilities are eligible for big federal payments.
The reason? Becoming a rural emergency hospital means losing access to 340B, and that, financially, is a bridge too far. The story underscores the tension around 340B. It truly is a lifeline for certain hospitals, but it has taken on such outsized importance that 340B considerations trump almost everything. That’s a rickety structure on which to build a health care system.
Elsewhere:
Speaking of 340B: both Politico and Fierce wrote on the new House bill to overhaul the 340B program. It’s pretty clear that the battle lines are being drawn. On the one side are manufacturers and community health centers, whose line is “the system is way broken.” On the other side is hospitals, whose position seems to be “broken or not, we need the money.” Should make for an interesting debate.
This Reuters piece says that we may end up spending $150 billion a year on obesity meds, which is a hard number to wrap one’s head around. On the one hand, that seems really high, especially in the context of falling prices. On the other hand, IQVIA’s oncology numbers suggest that we’ll be spending $400 billion on cancer care — including around $90 billion on a single class (PD-1s) — by 2028. So maybe, in context, $150 billion isn’t that outrageous. (I still think that’s a hugely rosy estimate.)
I don’t think you all, as Cost Curve readers, will learn anything new from this LA Times piece on obesity-med spending. It’s a pretty surface take, even though a lot of people are quoted, and I think it underscores the reality that a lot of Americans and, maybe, some reporters just don’t quite get how the system works.
So there is broad agreement that almost everything about the new pill for postpartum depression is encouraging. There’s a need, docs like it, it’s working for patients. The one issue, per this NBC piece: insurance companies. Sigh.
Header image via Flickr user frankieleon.
