By: Peter J. Pitts
Health and Human Services Secretary Alex Azar wants to make prescription drug pricing more transparent.
We agree, but his well-intentioned plan will only confuse and mislead consumers. What’s the good of listing drug prices in advertising if almost no one pays that “list price?” When patients say, “My drugs are too expensive,” they’re not talking about the list price — they’re talking about their co-pays at the pharmacy.
While pharmaceutical companies determine a drug’s list price, known as the wholesale acquisition cost (WAC), health insurers and pharmacy benefit managers (PBMs) determine what patients will actually pay for those drugs. These “payers” negotiate discounts and rebates from drug companies that can reach 40 percent or 50 percent off the WAC price. Unfortunately, these health care middlemen keep much of those savings and pass only a paltry portion of the discounts on to consumers.
Even more troubling is that unlike other health care sectors, patients’ copays and coinsurance are often based on the higher list price rather than the significantly discounted payer cost. According to a 2017 study by Amundsen Consulting, more than 50 percent of commercially-insured patients’ out-of-pocket spending for brand name biopharmaceuticals was based on full list price, with no discounts included.
When patients complain about the high cost of drugs it’s because their copays have grown significantly. Today many insurers require a co-insurance payment of 20 percent to 40 percent of the cost for innovative drugs for serious and life-threatening conditions, such as multiple sclerosis and rheumatoid arthritis.
Over the last five years, pharmaceutical spending has increased by 38 percent while the average individual health insurance premium has increased by 107 percent. During the same period, rebates, discounts and fees paid by the biopharmaceutical industry to insurers and PBMs have risen from $74 billion to $153 billion.
Fortunately, President Donald Trump and Congress have taken some steps in the right direction. The president recently signed legislation outlawing PBM-imposed “gag clauses,” which prohibited many pharmacists from voluntarily informing customers that paying for a drug out of pocket was less expensive than their copay.
And Food and Drug Commissioner Scott Gottlieb is working to increase competition between brand name companies and generics.
A key problem with Mr. Azar’s transparency effort is that it doesn’t provide consumers with any context or insights into the complexity of the drug-pricing ecosystem. Nor does it change the convoluted incentives that leave most of the negotiated savings with middlemen instead of patients.
What’s the solution? Real, complete, honest consumer-friendly pricing transparency that gives patients the ways and means to become smarter, savvier value-conscious shoppers in the healthcare marketplace by giving them clear, understandable and relevant pricing information.
Rather than opting for the cheap, politically expedient trick of “blaming Big Pharma,” our national leadership should insist that all members of the healthcare ecosystem create expert-vetted, user-friendly education programs so that patients know the real costs of what they’re buying, where the profits are going and, most importantly, how they can use this knowledge to become savvier consumers.
Peter J. Pitts, a former Food and Drug Administration associate commissioner, is president of the Center for Medicine in the Public Interest. Merrill Matthews is a resident scholar with the Institute for Policy Innovation.