A running theme at the Asembia 2017 Specialty Pharmacy Summit was the explosive growth in attendance from several hundred a few years ago to greater than 6,000 in attendance in 2017. Pharmaceutical and Biological (Pharma/Bio) manufacturers were the dominant presence at Asembia, which is no surprise given their pricing power in the specialty drug market, which prioritizes protecting and rewarding intellectual property (IP). It’s very interesting that 20-years ago, Pharma Manufacturers were chasing major disease categories like diabetes and coronary disease which impacted large swaths of the US population. Now, they are carving up finer segments of diseases to generate specialty blockbusters that target less than 2% of the US population. As Mike Einodshofer, CIO at Maxor discussed, the primary goal for payors is to preserve the healthcare benefit for all participating members. Yet the trend drivers are concentrated on innovative therapies that target smaller and smaller populations. These contradictory goals lead us to the billion-dollar question: How do we address the unsustainable conundrum of an unstoppable specialty price trend force met with an immovable benefit obligation object?
The point is, given current obligations in the healthcare market, there’s little money left to accommodate continued double digit price trends for specialty drug therapies…
So, here are 10 contributing trends related to the specialty market that might motivate us to action:
- Einodshofer from Maxor also shared that 20% of healthcare spend goes to diabetes, providing an obvious example of existing, competing cost pressures.
- Liz Barrett, Global President & GM of Oncology at Pfizer jumped into the mix and reflected on current scientific indications that 40% of adults will be diagnosed in their lifetime with some degree of Alzheimer’s.
- A third (1/3) of Medicare patients who were prescribed the leukemia therapy imatinib mesylate, which achieves remission with the clear majority of patients, did not fill a prescription due in part to the cost of therapy totaling $146K. (source: Elwyn Pharmacy)
- Prescription drug spend is projected to be $455B in 2022, which is ~10-12% of total healthcare costs. (source: CMS)
- Also by 2022, Marc Stranz, VP of Compliance and Mala Crossley from Elwyn Pharmacy Group pointed out that Orphan Drugs (treating ~25M US patients concentrated in 350 rare diseases) will cost $209B, or 46% of the overall Rx spend! There are 552 approved drugs in orphan-status with an average course of treatment of $140K. Picture 25M patients X $140K for treatment; this equates to too many zeroes to be even remotely sustainable.
- To further demonstrate this conundrum, we heard in one employer case that 60% of Rx spend went to just 1.6% of the population receiving specialty drug therapies. Mike Evans from Geisinger Health System, shared that 1% of the claims that cover specialty drugs represent 36% of Rx spend in his system.
- A few questionable factors have distracted the media, and us, from focusing on these key trends – whether its Epipen inflation, $50K generic drugs that were approved in 1953, or Enflaza’s staggering 800% increase upon entry into the US market, every stakeholder that takes their cut should weigh profits against their obligation to achieving patient wellness.
- We witnessed Payors and Manufacturers kicking the can down the street on value-based specialty contracts. The lack of an intermediary , limited provider collaboration on disease management and lack of competition contributed to a stunt in the growth of value-based arrangements. Without naming names, the pricing power that Pharma has over Specialty breeds distrust and undermines progress in collaborating on drug target populations or budget impact for new drugs and new indications.
The point is, there needs to be a little less cheer-leading and more discussion around fixing the underlying issues. The symptoms of an unsustainable Specialty Drug trend will increasingly impact access to care for everyone without collaboration and compromise.
So, as an optimistic contributor to the solution, we are working hard to help our Payor, Pharma Manufacturer and Provider customers more closely track medical drug spend. We continuously refine our data to ensure proper utilization and pricing for the high cost and high touch pharmaceuticals that typically treat our nations’ sickest citizens.
Please do not hesitate to share your comments and join our community in our quest to improve data quality and control over medical drug spend.