Tag Archives: Medicare

Should the Government Regulate Prescription Prices, Part 1

Consider these recent headlines:

The cost of Biogen’s new drug: $750,000 per patient

Gilead’s New Hepatitis C Drug Approved by FDA, Priced at $74,760

Hospitals Furious at Cancer-Drug Price Hikes

Got Insurance? You Still May Pay A Steep Price For Prescriptions

There is quite a bit of unhappiness about drug prices these days.  One of the proposed solutions to the problem of high drug prices is to have the federal government negotiate or regulate prices.  In the next few blog posts, I’ll examine various arguments that support government regulation of prescription drug prices and some that oppose it.  But first, in this post, I’ll provide some basic background on the prescription drug market that I think is useful in understanding the arguments for and against government regulation of prescription prices. Continue reading

What are DIRs?

Prescription drug pricing and reimbursement are complicated and confusing as it is.  DIRs have only made them more so.  And much more painful for community pharmacies.

What are DIRs?

DIR stands for Direct and Indirect Remuneration.  The term was initially used by the Centers for Medicare and Medicaid Services (CMS) to refer to all price concessions which PBMs and plan sponsors (insurance companies, HMOs, chains and PBMs offering Medicare Part D plans) receive for Part D prescription drugs that were not included in the point of sale transaction (i.e., when the drug was dispensed to the patient and the charge sent to the plan sponsor or PBM).  CMS reconciles payments to plan sponsors at the end of each year and one of the reconciliation involves reducing plan reimbursements by the amount of the DIRs received by plan sponsors.

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DrugAbacus – a tool for estimating the value of cancer drugs

Do cancer drugs provide good value or are they overpriced?  Last week’s post discussed the value framework introduced by ASCO for evaluating the value of cancer drugs.  This week we will look at another approach to estimating  the value of cancer drugs – the DrugAbacus interactive tool  developed by Sloan Memorial Kettering Cancer Center.    According to a recent Wall Street Journal article, Dr. Peter Bach developed DrugAbacus “to get drug makers, insurers, doctors and patients talking about the factors that should determine price” and to develop “a value-driven system for pricing cancer drugs”.  A screenshot of the tool is shown below.

drugabacus screenshot

 

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ASCO releases value framework for assessing value of cancer drugs

It’s no surprise that costs of cancer drugs are high.  Recent estimates put the average cost of cancer drugs at $10,000 per month with some therapies costing as much as $65,000 per month.  If it weren’t for insurance, prices this high would put cancer drug therapy out of reach for most families.  Even with insurance, many families cannot afford cancer drugs because of high patient cost sharing.  Many insurance programs, such as the Medicare Part D program, set patient cost sharing as a percentage of the drug’s cost (usually in the 20% to 30% range) rather than as a fixed dollar amount.  Medicare Part B, which covers most injectable cancer drugs, has a patient cost share of 20%.  How many families can afford cost sharing of $2,000 to $3,000 per month?

Oncologists and their professional organizations are concerned about this and have taken steps to address the problem.   The WSJ  recently reported that Memorial Sloan Kettering Cancer Center has developed an on-line, interactive tool to help physicians and patients determine what cancer drugs are worth.  I will discuss this tool in next week’s post.  Today’s post will discuss a value framework for assessing the value of cancer drugs that was recently announced by the American Society of Clinical Oncology (ASCO),  the professional organization representing oncologists.

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Discounts, rebates and kickbacks

One of the purposes of this blog is to educate readers about basic issues in pharmacy business.  This post will discuss the differences between discounts, rebates, and kickbacks.  Warning – I am not a lawyer and this is not a legal opinion.  It’s a non-lawyer’s attempt to understand and explain some basic pharmacy business concepts.

A headline on the Wall Street Journal Health Blog from earlier this year announced that “AstraZeneca Pays $7.9M to Settle Kickback Charges Paid to a PBM”   The federal government alleged that AstraZeneca made illegal rebate payments to Medco in exchange for preferred formulary position for Nexium (a very popular drug prescribed for ulcers).

Pharmaceutical companies commonly provide rebates to PBMs and specialty pharmacies to increase use of their products, so why was the rebate in this situation a kickback? Continue reading