Adam J. Fein
@DrugChannels
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Expert insights from Dr. Adam J. Fein on pharmaceutical economics and the drug distribution system. Contact me at afein @drugchannels .net
Philadelphia, PA
Joined March 2009
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Fascinating interview with
@mcuban
about
@costplusdrugs
and how he is attacking
#pharmacy
&
#PBM
industries
His key point: Manufacturers are not the problem. Big 3 PBMs are distorting
#drug
prices.
Definitely worth watching (start at 4:50)
28
88
304
Question of the day: Why is it called a "Randomized double blind placebo control study" instead of "Trick or Treatment"?
Happy Halloween!
7
68
277
Hospital-employed physicians love benchmarking U.S.
#drug
prices vs. other countries.
Wake me up when they propose benchmarking their salaries & hospital prices to other countries. 👇 🙄
FYI: U.S.
#healthcare
spending = $3.8 trillion
Drugs ~15% / Hosp+MDs ~60%
#justsayin
16
61
264
Per
@Altarum
, prescription
#drugs
are (and will be) <14% of total U.S.
#healthcare
spending
Updated lesson: Pharmaceuticals account for 14% of U.S. healthcare spending, but absorb 99% of the political heat.
#facts
#data
7
42
135
Thoughtful commentary from the one and only Mark Cuban
@mcuban
on core problems with
#PBM
market from today's
@WhiteHouse
listening session. Worth watching! (Link starts at 49:47)
6
38
125
From Mark Cuban
@mcuban
: Five Ways that Big hashtag
#PBMs
Hurt U.S. Healthcare–And How We Can Fix It
A Drug Channels exclusive op-ed from the founder of
@costplusdrugs
==>
6
43
118
Wow! Per new
@Health_Affairs
article,
#pharmaceuticals
are (on average) responsible for 35% of total increase in U.S. life expectancy
Drugs made an even greater contribution for
#HIV
(76%), heart disease (52%), and breast
#cancer
(60%)
3
62
119
Outstanding op-ed: "Regeneron wasn’t paying ‘kickbacks.’ It was helping people pay egregious
#Medicare
copays"
@statnews
I hope the pharma industry’s many critics think hard about the arguments that
@PeterKolchinsky
makes here.
8
33
112
Today is the birthday of John Venn, inventor of the Venn Diagram!
4
40
114
Mapping the Vertical Integration of Insurers, PBMs, Specialty Pharmacies, and Providers: A 2022 Update
My updated look at the state of U.S. drug channels
==>
4
42
111
WOW!
@Coherus_Bio
$CHRS launches bold
#Humira
#biosimilar
price war via
@mcuban
@costplusdrugs
YUSIMRY=$569+shipping (WAC=$995; -85% vs.
@abbvie
$ABBV)
#PBMs
will rapidly lose control of this market. Are plans paying attention as
#GrossToNetBubble
pops?
7
23
103
Enjoyed meeting with
@mcuban
to learn more about his vision for
@costplusdrugs
and how he wants to change the drug channel. Much more to come!
8
2
103
Fantastic report from
@46brooklyndata
on
#PBM
specialty drug formulary games:
- Inconsistent definitions of "specialty"
- Massive spreads on low-cost specialty
#generic
#drugs
- Huge mark-ups vs.
@mcuban
@costplusdrugs
cash prices
👎👎
7
27
87
Fun fact for your weekend: Hospitals and physicians (not pharmaceuticals) are key drivers of higher healthcare costs in the U.S. vs. other countries
Latest data from
@KFF
@PetersonCHealth
👇
Yet policy focuses only on benchmarking
#drug
spending 🤷
2
21
90
Warped incentives update: Humira retains 99% of market share, despite being more expensive than
#biosimilars
.
#PBMs
& specialty
#pharmacies
both benefit from retaining higher-cost
#drug
. 🙄
Great report from
@BiosimsCouncil
&
@IQVIA_global
==>
3
24
82
I highly recommend Mark Cuban
@mcuban
@AccessibleMeds
transcript.
Here's his take on why U.S.
#drug
channel is so messed up. 👇 Cuban calls out vertically integrated
#insurer
/
#PBM
/
#pharmacy
companies!
When will he take on
#GrossToNetBubble
products?
5
20
80
Mapping the Vertical Integration of Insurers, PBMs, Specialty Pharmacies, and Providers: A May 2024 Update
U.S. healthcare 101...
@BCBSAssociation
@Centene
$CNC
@Cigna
$CI
@CVSHealth
$CVS
@ElevanceHealth
$ELV
@Humana
$HUM
@UnitedHealthGrp
$UNH
5
22
80
FYI,
#GrossToNetBubble
is alive and well for GLP-1s. 👇 For 2024, Novo Nordisk will pay rebates of 49% to CVS Caremark for obesity drugs used in North Carolina, i.e., these drugs will sell for half of their list price.
Nice find,
@brianreid
==>
5
20
76
Wow.
#Pharmacy
benefits are broken. For 2020:
1.
#PBMs
paid
@GoodRx
$GDRX $488 million (+34% vs. '19) 👇
2. GoodRx = ~$3.4 B of U.S.
#prescription
revenues (~1% of total
#Rx
mkt)
3. 70% of consumers had comm'l ins. or Medicare - but used GoodRx anyway!
5
20
71
Wow. Secretary Becerra's
@SecBecerra
testimony was painful to watch, because he was deeply misinformed about the facts and seemed to directly misrepresent
@HHSGov
actions on
#accumulators
. Shameful. Kudos to
@RepBuddyCarter
Watch for yourself:
10
29
70
Congratulations to
@AltoPharmacy
for again being named to the
@CNBC
Disruptor 50 list! I'm glad to be involved with this innovative business and the Altoids who work there.
9
11
67
Credit where credit is due:
@JohnArnoldFndtn
has finally discovered that
#hospital
prices are the biggest driver of U.S.
#healthcare
costs
Good
@_melaevans
@WSJ
reporting on
@Arnold_Ventures
previously unreported funding for lawsuits against hospital M&A
3
13
68
Surprise! Brand-Name Drug Prices Fell (Again) in 2020
An update on the only part of US
#healthcare
where prices have declined--and why it's happening
#facts
3
23
64
Useful report on
#biosimilar
landscape from
@Healthcare_ABC
$ABC
My $0.02: Adoption rates growing quickly, competition increasing, prices falling. The biosim market is finally beginning to fulfill its promise.
5
22
62
Great observation in
@Health_Affairs
:
"Medicines represent roughly 15 percent of US health care expenditures, yet they are the focus of almost half of published cost-effectiveness analyses..."
@Altarum
@TuftsCEVR
@SchaefferCenter
1
12
59
Excellent new
@Amgen
#biosimilar
trend report finds prices dropping and adoption accelerating
Lots of good data and charts. Highly recommended! 👍👍
@ScottGottliebMD
was right. Market forces work.
#NoTowel
Full report (free) ==>
3
14
64
Check out this super important study about
#prescription
pricing,
#PBMs
,
#pharmacy
economics, and how the drug channel actually functions. Great work,
@A_Ciaccia
!
Big PBMs say “Drugmakers alone have the power to set prices.”
Then how is that the same PBM set five different prices for the same drug, at the same pharmacy, on the same day, where the delta between the bookends had an over 10x difference?
Our latest:
11
77
169
1
20
63
From
@PioneerBoston
and
@PopovianPharmD
: "The Out-of-Pocket Cost Ponzi Scheme"
More criticism of
#copay
#accumulators
and
#maximizers
==>
@RealClearHealth
0
2
9
Recommended weekend reading: Strong letter from 3 U.S. senators describing negative role of
#PBMs
on
#insulin
pricing (
#GrossToNetBubble
) and urging
@FTC
investigation. Definitely worth your time.
@ChuckGrassley
@RonWyden
@SenatorBraun
12
29
60
Huh? Cash prices were *lower* than commercial
#insurer
negotiated rates for nearly half of
#hospital
procedures
Remind me again why
#insurers
are such great negotiators. Sounds like
#PBMs
and
#generic
#prescriptions
@Health_Affairs
6
16
61
Seriously?!?
@UHC
$UNH new copay
#accumulator
policy requires
#physicians
and other healthcare professionals to rat out patients who use copay coupons for
#medical
benefit
#drugs
So, doctors now must enforce punitive benefit designs? Boo. 👎👎
14
27
60
Per
@SSRHealth
: Brand-name
#drug
prices have been dropping for 2 years! For 2020Q2:
- WAC list prices up +3.6%, but net prices down -5.1%
- Net prices = 49.9% of list prices
Crazy that patients still pay coinsurance and deductibles based on list
(Sorry, no link for full report)
7
25
61
Strong evidence that
#hospitals
are blocking
#biosimilars
to profit from higher-priced
#brand
#drugs
. Per Ronny Gal
@BernsteinPWM
, most hospitals don't even have
#biosimilars
available for use!
P.S. Due to
#340B
, hospitals prefer higher priced
#drugs
5
22
58
Whoa.
@BCBSNebraska
pays brokers more to shift
#PBM
business to Prime Therapeutics
@Prime_PBM
Guess what? BCBS partially owns Prime 😑
Great investigative journalism by
@bobjherman
@statnews
==>
5
24
59
Mind blowing margins:
#Hospitals
markup CAR-T by 300%+ over WAC
Even at lowest
#340B
discounts,
#hospitals
absorb ~2/3 of $$ that comm'l plans
@UHC
&
@BCBSAssociation
spend on CAR-T (and also get medical payments on top of these spreads)
Fantastic work by
@rgalBernstein
3
19
58
Kudos on a clever analysis!
My $0.02: Patients who cover their own costs will shop for cheaper prescriptions. Rather than harness these market forces, Medicare plans overcharge for common, low-priced generics but make seniors pay excessive OOP costs for rare specialty drugs.🙄
NEW STUDY: Medicare could have saved up to $3.6 billion in 2020 if it bought 77 generic drugs at prices by Mark Cuban's
@costplusdrugs
prices! 💵💵💵
Published today in
@AnnalsofIM
with
@bnrome
@akesselheim
via
@PORTAL_Research
🧵
61
425
1K
0
11
56
Thought provoking comparison via PhRMA:
#Drug
prices for cardiovascular disease have plunged, while surgical prices have skyrocketed.
As
@PeterKolchinsky
says:
#Hospitals
don't go generic, but drugs can.
1
19
54
Great quote from
@mcuban
@costplusdrugs
: "If the big three
#PBMs
, which also own the insurance companies, lose five of the top 15 non-PBM Fortune 50 companies, their business practices are going to change.”
#capitalism
==>
3
15
58
Excellent reminder from
@46brooklyndata
: Health plans profit—and patients lose—from highly-rebated brand-name
#drugs
👇
Great "Money from sick people" analysis of
#Lantus
#Insulin
and warped economics of U.S. drug channel
@A_Ciaccia
#PBM
0
15
55
A shameful top 10:
#Hospitals
that spend the least on charity care and community investment vs. value of their "non-profit" tax exemptions
Extra irony: Most are
#340B
covered entities, too 🙄
@lowninstitute
3
33
56
Insurers + PBMs + Specialty Pharmacies + Providers: Will Vertical Consolidation Disrupt Drug Channels in 2020?
6
13
54
Huh?
@CVSHealth
$CVS
#PBM
admits "plan sponsors will benefit from significant savings" of
#biosimilars
Sorry, patients!
#Amjevita
(list price -55% vs.
#Humira
) is non-preferred, i.e., not lowest cost for patients with deductibles or coinsurance
Yuck.
4
15
55
Really, Peter?!? We could benchmark *any* aspect of U.S.
#healthcare
to international prices and free up a “ton on money.”
Wake me up when
#physicians
propose benchmarking their salaries to other countries’ pay scales.
Data from
@Medscape
(sorry, no direct link)
In
@bopinion
I wrote abt
@SpeakerPelosi
drug price negotiation bill. It frees up ton of money that could improve health, and improves Rx adherence, curtails drug development only minimally. Legit question whether society better off with it or status quo
1
5
15
10
9
53
Is this how "medical" insurance should work?
Per recent
@Health_Affairs
paper, health plans' step therapy rules are more stringent than clinical recommendations
Full study:
(See Appendix Exhibit E)
Graphic :
@garykarr
@RealChemistry_
3
15
53
Hmm.
#Telehealth
visits have plummeted since reopening began. Down from 70% of total ambulatory visits in April to only 21% in July.
I wonder how much telehealth will remain when things really get back to normal. 10%? 15%?
Source: Epic Systems
11
17
52
Highly recommended! New
@Amgen
2022
#Biosimilars
Trend Report (free)
Loads of neat data by therapeutic class.
In big categories, ASPs are now down -60% or more
2
13
51
Big copay
#accumulator
news!
@USDC_DCCircuit
struck down
@HHSgov
rule allowing non-grandfathered individual & group plans to exclude manuf copay assistance from deductibles
Huge win for patients thanks to
@HIVHep
,
@DiabetesPAC
, &
@DiabetesLeaders
==>
3
16
52
Shameful
#PBM
#pharmacy
markups for nonbiological generic
#drugs
vs.
@costplusdrugs
reflect the ongoing battle for
#oncology
margin. Wake up, plans!
@CVSHealth
$CVS
@ExpressScripts
$CI
@OptumRx
$UNH
@joewalkerWSJ
@WSJ
@46brooklyndata
@mcuban
1
25
51
Mapping the Vertical Integration of Insurers,
#PBMs
, Specialty
#Pharmacies
, and Providers: A May 2023 Update
By popular request...
@BCBSAssociation
@Centene
$CNC
@Cigna
$CI
@CVSHealth
$CVS
@ElevanceHealth
$ELV
@Humana
$HUM
@UnitedHealthGrp
$UNH
2
13
52
Big
#biosimilar
news: Ronny Gal
@AB_insights
calculates that
#biosimilar
savings are now $6.5 billion (annualized) and growing 👇
Spending down -31% for reference molecules
@ScottGottliebMD
was right. We shouldn’t give up on biosimilars
#notowel
(Sorry, no link to full report)
1
17
52
Venture capitalist Bruce Booth
@LifeSciVC
lays out many uncomfortable truths about
#drug
pricing, innovation, R&D, policy,
#GrossToNetBubble
, & more
@Forbes
Well done and very timely given nonsensical talking points from our politicians. Kudos, Bruce.
0
10
51
Weekend reading: Fantastic article describing the history and channel roles of
#PBMs
. Nice discussion of tradeoffs between (1) addressing market failures vs. (2) protecting other channel participants.
@joeymattingly
@GeBaiDC
3
12
50
Hey,
@pcmanet
! If you (misleadingly) complain that "drug companies set the prices of the products they make and sell," you should also explain why plans &
#PBMs
limit access to
#biosimilars
with lower prices, e.g., Semglee, Amjevita
7
10
51
Surprise! Brand-Name Drug Prices Fell (Again) in 2020 (rerun)
No other part of U.S.
#healthcare
has seen its prices drop year after year. Politicians, journalists, and academics who focus on list prices distort the truth about
#drug
prices.
#facts
5
19
50
A personal note: I want to acknowledge Tashara C, a
#pharmacy
technician at
@cvspharmacy
at 1919 Market St in Philly. She handled a complex issue with my prescription—and did so with a smile and a great attitude. Always a pleasure to meet people like her in a pharmacy.
5
3
49
Ugh. Misleading, deceptive "research" via
@GoodRx
:
- Compares
#drug
*list* prices to net
#healthcare
prices
- Falsely claims patients paying more (not true per CMS NHE stats)
- Ignores BLS index flat since 2018
Hope its SEC filings are more accurate!
3
8
47
We still have
#GrossToNetBubble
problem:
1. Humira's list price skyrockets
2. Net price received by
@abbvie
$ABBV grows slowly b/c of
#PBM
#rebates
3. Plans use $$ to reduce premiums for healthy
4. Patient OOP grows along with list--not net--price (reverse insurance)
Crazy!
How to get to > $20,000,000,000 per year:
The
#1
drug—Humira—had a price increase from $2,914 to $5,174 over the past 5 years, largely thanks to the 611% jump by the abominable pharmacy benefit managers. Leading to a near doubling of what the patient pays
20
158
244
2
18
48
Great op-ed by Bret Stephens
@nytimes
: The Story of
#Remdesivir
@GileadSciences
$GILD
"Just as there are no atheists in foxholes, there should be no big-pharma haters in pandemics." 👍👍
2
16
45
Hooray! For the first time ever,
@HRSAgov
has posted
#340B
covered entity purchases on its website 👏👏👏
I presume HRSA finally got tired of my FOIA requests 😉
P.S. Historical data by CE on Drug Channels:
#RegulatoryCapture
1
14
45
Excellent new 2022
@Amgen
#biosimilar
trend report:
1) Biosim prices decreasing at 9% to 22% *per year*
2) Avg share=74% (in thera areas w/biosims launched in last 3 years)
Market forces at work!
#NoTowel
Full report (free):
0
6
46
👀
Today, Congress took a huge step towards shining a light on the pharmaceutical industry’s shadowy middlemen. Thank you to
@GOPoversight
for allowing me to speak at this important hearing.
18
53
178
3
4
47
Another independent, credible source uncovers massive
#340B
grift & greed.
#FacesOf340B
= Zero transparency, no accountability, financial diversion, and outright fraud
When will Congress fix the out-of-control, unregulated
#340B
program?
2
12
48
Whoa!
@CMSGov
best price rule sharply criticizes
#PBM
abuses of
#copay
#accumulator
programs that divert patient assistance funds from patients to plans (p 46)
Looking at you,
@CVSHealth
$CVS (PrudentRx) and
@ExpressScripts
$ESRX (SaveonSP)! 👀
6
22
45
Behind the
@GoodRx
/
@ExpressScripts
Partnership: How
#PBMs
Profit from Discount Cards in
#Pharmacy
Benefits
My latest peek under the coconuts...
$GDRX $CI
7
14
46
Wow.
#340B
was ~20% of
#Medicare
Part D claims in 2020, i.e.,
#BecauseOf340B
, seniors & taxpayers :
1. overpaid for prescriptions that
#hospitals
bought for $0.01
2. funded
#340B
profits earned by covered entities &
#PBM
contract
#pharmacies
==>
4
11
45
U.S.
#healthcare
craziness: For *same* specialty
#drug
, the *same* health plan has *different* step therapy requirements for
#Medicare
Advantage vs. commercial
Also: unexplained diffs between plans for the same drug
What a mess.
@AJMC_Journal
==>
0
11
45
Warped incentives update: 55% of
#generic
#drugs
on non-generic tiers in
#Medicare
#PartD
@avalerehealth
- 20% on "Preferred Brand" tier (huh?)
- 29% "Non-Preferred" (vs. equivalent brand?)
- DIR/rebates? Net costs?
Need to fix Part D benefit design!
9
7
46
A joke (?) via
@TheOnion
: Health Insurance CEO Reveals Key To Company’s Success Is Not Paying For Customers’ Medical Care
1
11
46
Wow!
#GrossToNetBubble
for GLP-1s in
#Medicare
reached $3.1 billion for 2022
Gross payments to pharmacies = $5.7B
Net revenues to manufacturer = $2.6B
Sources:
@KFF
:
@AEI
:
@jcubanski
@ben_ippolito
@tricia_neuman
@SpongeBob
#DIR
2
13
46
More from
@rgalBernstein
👇
1)
#Insurers
pay wildly different prices for same
#drug
(
@Humana
@Cigna
et al)
2)
#Hospitals
get massive markups over
#ASP
🤯
3) Manuf can earn minority (<20%) of drug cost to third-party payer (esp. w/
#340B
)
@CMSGov
data:
0
22
45
Well said,
@C_Garthwaite
!
"If we want cures to diseases like COVID-19, we should stop vilifying
#drug
companies"
4
10
45
#BecauseOf340B
,
@PennMedicine
got $717M from
#340B
program, but charity+Medicaid care was only $419M.
This $10B nonprofit
#hospital
system has basic community benefit spending requirements. Where did the extra $$$ go???
#FacesOf340B
@PhillyInquirer
7
19
44
New
@GoodRx
$GDRX investor deck succinctly explains company's profit model 👇
Easy to see why
#pharmacies
are unhappy and
#PBMs
are wary
My $0.02 here:
4
11
44
Yikes. Many people misunderstand basic insurance terms.
% who can't correctly define:
Deductible: 45%
Copayment: 46%
Coinsurance: 77% (!)
Yet 85% are very/somewhat happy with their insurance plan ¯\_(ツ)_/¯
Source:
@Forbes
survey of 2,000 Americans
6
19
39
FYI: 10
#drugs
with total sales of $17.4 B will lose exclusivity in 2022, removing billions in U.S. healthcare spending
Revlimid = $8.7 B (50%)
As
@PeterKolchinsky
has noted:
#Hospitals
and
#physicians
never go generic, so their costs keep growing...
3
15
41
Great new
@JanssenUS
$JNJ transparency report on
#drug
pricing &
#GrossToNetBubble
#Rebates
/discounts/fees=$39 B in 2022 (58% of gross revs):
- Comm'l payers/
#PBMs
: $11.2 B
-
#340B
: $6.2 B
-
#Medicare
: $5.1 B
P. 8: As Net Prices Decline, Who Benefits?
2
14
43
Let's kick off 2022 with an
#insulin
#GrossToNetBubble
update
Per
@millimanhealth
:
Net cost / patient = $88/month
Rebates + discounts / patient = $448/month (!)
Nutty math = warped
#PBM
incentives + flawed drug pricing policies + overcharged patients
1
10
42
Ridiculous analysis. U.S. should figure out value for
#healthcare
products & services. Outsourcing to countries w/ vastly different economies/systems/standard is lazy & illogical.
We don't benchmark MD salaries and hospitals to international prices, despite TRILLIONS in savings.
International reference pricing in HR3 could save Medicare $83.5B, 52.3% of net spending.
In other words, even if we were to raise the price cap above 120% IPI, there’s still *huge* savings to be had. 💰
Nice study by
@RANDCorporation
2
0
3
3
5
40
Fresh evidence of
#biosimilar
impact on
#drug
spending via
@medicarepayment
👇
Massive drops in
#Medicare
#PartB
payment rate b/c originator has either (1) slashed prices or (2) lost share to lower-priced biosimilars
#NoTowel
5
10
42
Want to know out-of-pocket costs for your
#prescription
?
Don't ask your
#physician
. They are also confused by benefit designs with deductibles, copays, coinsurance, & OOP maximums!
If well-educated MDs have trouble, how do you think patients feel? 🙄
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Must read:
@Carolynyjohnson
@washingtonpost
documents the challenges and hurdles she faced getting
@Aetna
to cover a crucial, medically-necessary specialty
#drug
for her 3-year-old son. Powerful and moving.
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Worthwhile weekend reading: "Why Drug Pricing Reform Is Complicated" by
@C_Garthwaite
&
@AmandaStarc1
Thoughtful, thorough look at the entire U.S.
#drug
channel and inescapable (but often ignored) tradeoffs of
#pharmaceutical
innovation 👍👍
@AspenEcon
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