The public furor with Big Pharma’s relentless skyward ratcheting of drug prices may be focusing soon on another set of medications, this time powerful anti-inflammatories, and the rising role played by middlemen in the dispensing process. The battle over Humira and Enbrel, taken for painful rheumatoid arthritis (RA), may expose even more the conflicting interests of patients, drug makers, insurers, and employers.
As the New York Times reported, the doubling of the prices for Humira and Enbrel has led Express Scripts, said to be the nation’s largest drug benefit management companies, to tell insurers and employers−which both rely on the firm to not only advise them on these issues but also to put out key lists of drugs covered under pharmaceutical benefits programs−to consider other anti-inflammatory drugs. The theory? It’s that “the new limits will force drug companies to lower their prices, saving insurers and employers money.”
By some calculations, Humira and Enbrel have become the nation’s “costliest drug class,” the New York Times says, noting, Express Scripts says they “account for nearly 10 percent of all drug spending among its members in the United States … costing an estimated $7.5 billion — even though fewer than 1 percent of its members use them.”
If Express Scripts’ actions can save money for insurers and employers, isn’t that ultimately good, too, for patients, who share an increasing portion of their health costs?
Not exactly. The New York Times points out that patients with RA, psoriasis, ulcerative colitis, and other complicated conditions can’t easily swap out other drugs with equal effect to Humira and Enbrel. They will endure pain and discomfort until they can find a suitable alternative, as one RA patient noted, adding, “even being a day or two behind can cause massive issues … .”
Besides its effects on patient-consumers, the struggle over Humira and Enbrel also will underscore the absence of transparency in drug pricing: Insured patients may pay little more than $100 a month for anti-inflammatories, which carry a monthly list price exceeding $4,000. Patient-consumer costs for medications can vary, for example, depending on whether they have high-deductible coverage.
Meantime, Express Scripts not only negotiates rebates and discounts with drug makers, it also pays them to encourage insurers, employers, and patient-consumers, as will be the case with the anti-inflammatories, to accept lower-cost medications.
As patient-customers have discovered in the EpiPen debacle with drug-maker Mylan, Big Pharma’s middl-men, like Express Scripts, play their own curious role in medication pricing. The prescription benefits managers (PBMs) are incentivized to cut costs throughout the dispensing side of the process−and they can reap big money from rebates and discounts they negotiate for insurers and employers, keeping an undisclosed portion of these hefty sums. The PBMs also squeeze those who dispense drugs, such as pharmacies, to keep costs down.
Express Scripts knows that the number of patients who take anti-inflammatories is relatively low. So it also has tried to prod them into its own pharmacy with pharmacists, said to specialize in inflammatory conditions. Critics say that as much as the PBM wants to curb costs, it also happens to be building this lucrative mail-order business, locking patient-consumers into it.
With drug prices zooming higher almost by the day, it’s clear that patient-consumers need giant help−from regulators, policy experts, lawmakers, and, yes, attorney advocates in the criminal and civil justice systems. The regular eruption of drug-pricing scandals is showing Americans that dealing with Big Pharma to get a fair shake is like wrestling with monstrous squid, with wriggling arms going all over and always reaching into the patient-consumers’ pocket. It’s disheartening, too, that slice by slice, groups of really sick people are left to struggle not only with their disease but also with gouging costs for drugs that could improve their well-being.