Drug Channels News Roundup, May 2023: 340B Shame, OptumRx vs. Humira Biosimilars, ICER on White Bagging, Hospitals vs. Taxes, and Dr. G

Summer unofficially began over the weekend. Check out these noteworthy delicacies, seared to perfection on the Drug Channels grill:

• Fresh evidence of 340B abuses by hospitals and contract pharmacies

• OptumRx rewrites its biosimilar Humira strategy

• ICER discovers channel markups

• Tax-exempt hospitals are not holding up their end of the bargain

Plus, Dr. Glaucomflecken helps you pick an insurance plan!

P.S. Join my more than 41,000 LinkedIn followers for daily links to neat stuff. You can also find my daily posts at @DrugChannels on Twitter, where I have more than 16,400 followers. (I recommend that you follow me on LinkedIn, because the quality of comments is much higher than they are on Twitter.)

Speaking of PBMs, be sure to join me for my new live video webinar, PBMs and the Battle Over Patient Support Funds: Accumulators, Maximizers, and Alternative Funding, on June 23, 2023, from 12:00 p.m. to 1:30 p.m. ET. Click here to learn more and sign up.

Five (or Maybe Six?) Reasons that the Largest PBMs Operate Group Purchasing Organizations

In The Top Pharmacy Benefit Managers of 2022: Market Share and Trends for the Biggest Companies, I shared Drug Channels Institute's analysis showing that three pharmacy benefit managers (PBMs)—the Caremark business of CVS Health, the Express Scripts business of Cigna, and the OptumRx business of UnitedHealth Group—accounted for about 80% of total equivalent prescription claims in 2022.

In recent years, each of these companies has launched new group purchasing organizations (GPOs) to further consolidate the number of covered lives in rebate negotiations with pharmaceutical manufacturers. Today, I examine these PBM-owned GPOs and then speculate on five plausible explanations for their existence. I also highlight a sixth, alleged rationale that is currently the subject of litigation.

The Federal Trade Commission (FTC) has recently started investigating these GPOs. I wonder if this additional focus will deepen the FTC’s ongoing investigation—or slow it down even further?

For more on PBMs, sign up for my new live video webinar, PBMs and the Battle Over Patient Support Funds: Accumulators, Maximizers, and Alternative Funding, on June 23, 2023, from 12:00 p.m. to 1:30 p.m. ET. Click here to learn more and register.

The Top Pharmacy Benefit Managers of 2022: Market Share and Trends for the Biggest Companies

In 2022, the PBM market remained highly consolidated—although there were some intriguing share shifts among the largest players.

Below, you’ll find Drug Channels Institute's latest estimates of pharmacy benefit manager (PBM) market share based on equivalent prescription claims. I also provide commentary on recent market developments and offer some helpful tips for interpreting the figures.

PBMs are facing unprecedented scrutiny from Congress, state legislatures, and the Federal Trade Commission (FTC)—although the PBMs' largest customers have not been vocally protesting the current marketplace. Tomorrow, I’ll examine one new evolution—the new group purchasing organizations that the largest PBMs have formed.

In the meantime, tune in for more PBM-bashing at today's House hearing: The Role of Pharmacy Benefit Managers in Prescription Drug Markets Part I: Self-Interest or Health Care?

Speaking of PBMs, join me for my new live video webinar, PBMs and the Battle Over Patient Support Funds: Accumulators, Maximizers, and Alternative Funding, on June 23, 2023, from 12:00 p.m. to 1:30 p.m. ET. Click here to learn more and sign up.

PBMs and the Battle Over Patient Support Funds:Accumulators, Maximizers, and Alternative Funding (NEW Live Video Webinar)

Dr. Adam J. Fein, CEO of Drug Channels Institute (DCI) and the author of Drug Channels, invites you to join him for a new video webinar:

PBMs and the Battle Over Patient Support Funds:
Accumulators, Maximizers, and Alternative Funding
This event will be broadcast live on
Friday, June 23, 2023, from 12:00 p.m. to 1:30 p.m. ET.

This page describes the event and explains how to purchase a registration. The webinar will be broadcast from the Drug Channels studio in beautiful downtown Philadelphia.

This event is part of The Drug Channels 2023 Video Webinar Series.

WHAT YOU WILL LEARN

As expensive specialty therapies come to dominate drug spending, pharmaceutical manufacturers are paying a growing share of patents’ out-of-pocket costs for these prescriptions. At the same time, plans and PBMs are turning to novel—and often controversial—benefit design tools that access manufacturers’ patient support spending.

Join Dr. Fein as he helps you and your team deepen your understanding of this complex subject and its crucial implications for drugmakers, payers, PBMs, and patients. During the event, Dr. Fein will cover a wide range of topics, including:

• What’s driving patients’ out-of-pocket obligations

• Trends in the value of manufacturers’ financial assistance

• Copayment offset programs vs. patient assistance programs (PAPs)

• Conventional pharmacy benefit management tactics

• The new tools that offset specialty drug costs: copay accumulators, maximizers, and alternative funding programs

• The latest market data on adoption of the new spending drug management tools

• Prescription economics of copay accumulators, maximizers, and alternative funding programs

• How PBMs profit from—and are challenged by—the new tools

• Plan sponsor perspectives

• State and federal legislation over pharmacy benefits

• Major lawsuits between manufacturers and vendors

• Outlook for specialty drug spending management

• Controversies and unresolved questions

• And more!

PLUS: During the webinar, Dr. Fein will give participants an opportunity to unmute themselves and ask live questions. The webinar will last 90 minutes to accommodate audience questions.

As always, Dr. Fein will clearly distinguish his opinions and interpretations from the objective facts and data. He will draw from exclusive information found in DCI's 2023 Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers.

Read on for full details on pricing and registration.

PRICING OPTIONS

You can register for this unique educational opportunity for only $380 per viewing device. Within 24 hours of your purchase, you will receive an email from Zoom with a unique link to access the live event.

We are offering substantial discounts for multiple registrations from the same organization. We know that many of you may be working remotely, so rates for multiple registrations are as low as $265 per device—a 30% savings. An unlimited number of people may watch at one physical location if they can watch from a single device. Please note that a device at a single physical location may not stream, share, or project our webinar to other sites. Each device at a physical location requires its own registration.

Click here to order. All discounts will be automatically computed based on the number of registrations you enter in your cart. (You can reset the cart by entering 0 in the quantity field.)

PBMs and the Battle Over Patient Support Funds:
Accumulators, Maximizers, and Alternative Funding

Please contact Paula Fein (paula@drugchannels.net) if you have any questions. If you purchase access for multiple devices, we will contact you for a list of your participants and their email addresses. Or, download this spreadsheet and email your registrants’ information to Tamra Feldman (admin@drugchannels.net).

Click here to register for the full Drug Channels 2023 Video Webinar Series

Payment can be made with all major credit cards (Visa, MasterCard, American Express, and Discover) or via PayPal. Click here to email us if you would like to pay by corporate purchase order or check.

IMPORTANT THINGS TO KNOW

• Watch and listen via any device with a web browser (computer, iPad, iPhone/Android, etc.) There is no access via telephone.

• We use Zoom technology for this webinar. Every registrant will receive an email from Zoom with a link to watch the event. This link is unique to the registrant and can only be accessed once. We recommend that every registrant download the Zoom client software/app.

• Within one day of purchasing a registration, each registrant will receive an email from Zoom with a link to access the event and add it to their calendar. Every registrant will also receive reminder emails from Zoom one week, one day, and one hour before the event.

• This event is part of The Drug Channels 2023 Video Webinar Series. If you have already purchased the full series, then you should have received an email from no-reply@zoom.us with your unique link to access the June event.

• Purchase of the webinar series includes a replay video of Drug Channels’ March 31, 2023, webinar Discount Cards, Cost-Plus Pharmacies, and PBMs: Trends, Controversies, and Outlook. Within 24 hours of purchasing the 2023 series, you will receive an email from Zoom with a link to access that video replay.

• Organizations that purchased corporate access for The Drug Channels 2023 Video Webinar Series will receive a custom, branded signup link so employees can easily register. We will automatically refund payments from anyone at a company with corporate access who purchases a single registration using their corporate email account.

• Unfortunately, we are unable to offer refunds.

Four Ways for Field Teams to Tackle Drug Utilization Management and Optimize Patient Access

Today’s guest post comes from Patrick Leary, Chief Commercial Officer at Phil, Inc.

Patrick describes how barriers to medication access affect manufacturers and patients. He offers four tactics that can help field teams unlock coverage for patients.

To learn more about Phil’s access and commercialization solutions, download their free whitepaper, Modernize the Patient Access Experience: Transform Your Pharmaceutical Brand. You can also visit https://phil.us/life-sciences/.

Read on for Patrick’s insights.

Employers Expand Use of Alternative Funding Programs—But Sustainability in Doubt as Loopholes Close

Last August, I warned you about alternative funding programs (AFPs)–the shady schemes by which commercial plan sponsors drop drug coverage in order to grab charity support intended for uninsured and indigent patients.

I’m sad to report that the manipulation of charitable patient assistance programs continues to expand. As you will see below, employers have significantly ramped up their adoption of AFPs, while health plans seem more skeptical. Meanwhile, a new AbbVie lawsuit sheds light on the alleged activities of a major AFP vendor.

Read on for our update on these suspect programs—and the growing risks to their sustainability. Caveat payer.

Adapt or Fall Behind: The Need for Agile Copay Programs in Today's Shifting Payer Landscape

Today’s guest post comes from Nasir Ali, Chief Product Officer at CareMetx

Nasir discusses manufacturers’ strategies for mitigating the patient impact of copay accumulators and maximizers. He then outlines two key tactics that manufacturers should include in hub programs.

To learn more how digitally-enabled hub programs help patients, download CareMetx’s report: The Evolving Landscape of Digital Healthcare Hubs.

Read on for Nasir’s insights. .

Mapping the Vertical Integration of Insurers, PBMs, Specialty Pharmacies, and Providers: A May 2023 Update

Yesterday’s reflections on Asembia’s Specialty Pharmacy Summit included a link to the general session slides. My portion of the deck included an updated mapping of vertical integration among insurers, PBMs, specialty pharmacies, and providers within U.S. drug channels. Many readers asked for a standalone version of this infamous chart.

So, for your viewing and slide making pleasure, below you’ll find my latest illustration of the major vertical business relationships among the largest companies.

I estimate that at least half of all public and private U.S. healthcare spending flows through these seven familiar entities: Blue Cross Blue Shield, Centene, Cigna, CVS Health, Elevance Health, Humana, and United Health Group. Just like the heroes in Dawn of the Seven, they are here to serve and protect you.

Enjoy the artwork. In the meantime, I suspect that vertical integration may come up during today's Senate hearing on insulin.

The State of the Specialty Market 2023: Reflections, Trends, and Photos from #Asembia23

Last week, Paula and I had the pleasure of attending Asembia’s 2023 Specialty Pharmacy Summit at the wonderful Wynn Las Vegas.

As I do every year, I will violate Vegas code and tell you what happened there. I offer reflections on my keynote session with Seema Verma, share my experiences during the featured session, and highlight some crucial specialty industry trends.

You’ll also find a link to my general session slides and some fun photos. FYI, Managed Healthcare Executive (accurately) described my presentation as "mixing jokes with data and PowerPoint slides." Yes, that sounds about right.

Enjoy!

RareMed Expands Concierge Patient Support Services to Complex Conditions

Today’s guest post comes from Justin Smerker, VP of Business Development at RareMed Solutions.

Justin introduces us to RareMed Solutions, a patient service provider that caters to patients with complex and rare diseases.

To learn about RareMed and their approach to the delivery of patient services for complex or rare conditions, visit www.raremed.com or email info@raremed.com.

Read on for Justin’s insights.

How Discount Cards Work: A Primer on GoodRx and Its Competitors (video)

In my most recent video webinar, I explored how the rapid expansion of patient-paid prescriptions—via cash-pay pharmacies and discount card vendors—is transforming the prescription market.

Below, I follow the dollar when a patient uses a discount card to pay for a generic drug prescription.

As you’ll see, a discount card can save money for consumers by leveraging several quirks of U.S. retail pharmacy pricing. Such cards also enable novel profit streams for both pharmacy benefit managers (PBMs) and the card vendors themselves.

For a deep dive into patient-paid prescriptions, see Sections 4.3. and 12.4.3. of our 2023 Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers.

Click here if you can’t see the video below.

If this clip whets your appetite for more, register to watch the full 90 minute Discount Cards, Cost-Plus Pharmacies, and PBMs: Trends, Controversies, and Outlook video webinar.