- Spooky! Blue Shield of California frightens away the gross-to-net bubble with its Humira biosimilar strategy
- Vampiric! Prior authorization sinks its fangs into providers’ time
- Wicked! How the IRA will put a stake through specialty physician practices
- Eerie! Google’s monstrous AI podcasts leave me petrified
- Zoinks! Join the vampire hunters at Drug Channels Institute
P.S. Stretch out your arms and join the ever-growing zombie horde who shamble after me on LinkedIn. You’ll find my ghostly rantings along with commentary from the undead hordes in the DCI community.
Blue Shield of California Slashes Cost of World’s Best-Selling Drug, Blue Shield of California
Look who’s popping the gross-to-net bubble!
ICYMI, Blue Shield of California will offer Fresenius Kabi’s Humira biosimilar for $525 per month. Like many manufacturers, Fresenius Kabi currently markets both a high-list-price brand-name biosimilar (Idacio; WAC = $6,576) and an unbranded low-list-price version (adalimumab-aacf; WAC = $899).
The deal was arranged by Evio Pharmacy Solutions, which is owned by Blue Shield of California and four other Blue Cross Blue Shield plans. Evio operates as a group purchasing organization for its Blues owners. Consequently, it’s unlike the vertical integration, private label strategies that CVS Health and Express Scripts are pursuing. (See Humira Biosimilar Price War Update.)
While I’ve been skeptical of BCBSCA’s overall strategy, I can’t deny that this was a good move for both patients and the drug channel.
Of course, it wouldn’t be a Blue Shield of California announcement without some unhinged PR puffery. In this case, the announcement touted the “the first time this unique business model has been used to bring a Humira biosimilar to market.” I suppose that’s true—but only if we ignore GoodRx/Boehringer Ingelheim or what the Mark Cuban Cost Plus Drug Company has been doing with Yusimry and multiple smaller PBMs.
ICYMI, Blue Shield of California will offer Fresenius Kabi’s Humira biosimilar for $525 per month. Like many manufacturers, Fresenius Kabi currently markets both a high-list-price brand-name biosimilar (Idacio; WAC = $6,576) and an unbranded low-list-price version (adalimumab-aacf; WAC = $899).
The deal was arranged by Evio Pharmacy Solutions, which is owned by Blue Shield of California and four other Blue Cross Blue Shield plans. Evio operates as a group purchasing organization for its Blues owners. Consequently, it’s unlike the vertical integration, private label strategies that CVS Health and Express Scripts are pursuing. (See Humira Biosimilar Price War Update.)
While I’ve been skeptical of BCBSCA’s overall strategy, I can’t deny that this was a good move for both patients and the drug channel.
Of course, it wouldn’t be a Blue Shield of California announcement without some unhinged PR puffery. In this case, the announcement touted the “the first time this unique business model has been used to bring a Humira biosimilar to market.” I suppose that’s true—but only if we ignore GoodRx/Boehringer Ingelheim or what the Mark Cuban Cost Plus Drug Company has been doing with Yusimry and multiple smaller PBMs.
Perceptions of prior authorization burden and solutions, Health Affairs Scholar
It’s not news that prior authorization (PA) puts a big burden on U.S. healthcare. This article quantifies the scale of that burden.
The authors surveyed patients, providers, and private payers. The chart below shows the reported median weekly hours spent on PA by 1,010 providers. As you can see, it’s a stunning amount of collective time that often leaves providers burned out and patients frustrated.
The article’s authors point to artificial intelligence (AI) as a possible solution. Many technology companies already sell solutions to improve the PA process.
BTW, my social media post about this article struck a nerve. It garnered nearly 45,000 views, more than 475 reactions, and dozens of comments from the DCI community.
The authors surveyed patients, providers, and private payers. The chart below shows the reported median weekly hours spent on PA by 1,010 providers. As you can see, it’s a stunning amount of collective time that often leaves providers burned out and patients frustrated.
[Click to Enlarge]
The article’s authors point to artificial intelligence (AI) as a possible solution. Many technology companies already sell solutions to improve the PA process.
BTW, my social media post about this article struck a nerve. It garnered nearly 45,000 views, more than 475 reactions, and dozens of comments from the DCI community.
Commercial Spillover Impact of Part B Negotiations on Physicians, Avalere
This Avalere analysis quantifies how the Inflation Reduction Act (IRA) will hurt physician practices. The news is pretty grim.
The IRA will directly reduce Medicare Part B reimbursement and indirectly reduce commercial reimbursements via the impact on average sales price (ASP). Thanks to the IRA, Avalere estimates that four specialties—oncology/hematology, immunology, respiratory, and neurology—will experience a 42% to 61% decline in Medicare reimbursements and a 12% to 18% decline in commercial reimbursements.
Shortly after IRA became law, I warned that the law would crush provider margins from buy-and-bill of provider-administered drugs. Section 6.5.2. in DCI’s new 2024-25 Economic Report on Pharmaceutical Wholesalers and Specialty Distributors expands on the industry dynamics for wholesalers and their physician practice customers.
Just another unintended consequence of this hastily passed law. So sorry, oncologists!
The IRA will directly reduce Medicare Part B reimbursement and indirectly reduce commercial reimbursements via the impact on average sales price (ASP). Thanks to the IRA, Avalere estimates that four specialties—oncology/hematology, immunology, respiratory, and neurology—will experience a 42% to 61% decline in Medicare reimbursements and a 12% to 18% decline in commercial reimbursements.
[Click to Enlarge]
Shortly after IRA became law, I warned that the law would crush provider margins from buy-and-bill of provider-administered drugs. Section 6.5.2. in DCI’s new 2024-25 Economic Report on Pharmaceutical Wholesalers and Specialty Distributors expands on the industry dynamics for wholesalers and their physician practice customers.
Just another unintended consequence of this hastily passed law. So sorry, oncologists!
The Gross-to-Net Bubble, The Deep Dive podcast
Will AI destroy the world?
I’m not sure, but Google’s new NotebookLM AI tool scared me enough to think it might be possible.
For fun, I plugged in a single Drug Channels article on the gross-to-net bubble. Listen to what it created:
This podcast took only minutes to create. It’s scarily good—and more human sounding than many actual podcasts. Give it a listen and prepare to have your mind blown.
For some background, read Google's AI podcast hosts draw crowds.
I’m not sure, but Google’s new NotebookLM AI tool scared me enough to think it might be possible.
For fun, I plugged in a single Drug Channels article on the gross-to-net bubble. Listen to what it created:
This podcast took only minutes to create. It’s scarily good—and more human sounding than many actual podcasts. Give it a listen and prepare to have your mind blown.
For some background, read Google's AI podcast hosts draw crowds.
Research Analyst, Drug Channels Institute, an HMP Global Company
We continue to expand our team here at Drug Channels Institute. We are currently recruiting a Research Analyst who will work directly with Adam J. Fein, Ph.D., and the DCI team to conduct original research on all commercial aspects of the U.S. pharmaceutical industry.
This is a fast-paced and rewarding role suited for those seeking high growth potential and expanding their knowledge in the healthcare space. It is a hybrid position in Boston, MA (preferred) or Philadelphia, PA.
Apply via LinkedIn:
This is a fast-paced and rewarding role suited for those seeking high growth potential and expanding their knowledge in the healthcare space. It is a hybrid position in Boston, MA (preferred) or Philadelphia, PA.
Apply via LinkedIn:
Copayments, Dr. Glaucomflecken
Dr. Glaucomflecken, the funniest physician on the internet, shares a spooky tale of patient cost sharing.
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