Express Scripts (ESI) has been drawing a lot of publicity recently over its strong stance on drug pricing and willingness to engage in exclusive formulary listing agreements for high-cost specialty drugs. Particularly with respect to hepatitis C drugs, ESI initiated an exclusive contract with AbbVie’s Viekira Pak (ombitasvir, paritaprevir and ritonavir tablets co-packaged with dasabuvir tablets,) which came second to market after Gilead’s Sovaldi (sofosbuvir) and Harvoni (sofosbuvir and ledipasvir).
Bloomberg recently published an interview with ESI’s chief medical officer, Steve Miller. The article states ESI’s intent to, after its perceived heroic act of negotiating rebates for Viekira, aggressively control the cost of anticancer drugs. What will this mean for patients?
Drug cost has become an increasingly sensitive topic worldwide. With the emergence of high patient co-payments for specialty drugs, many U.S. patients face substantial financial distress on top of the already emotionally challenging circumstances that a disease brings. Physicians and patients are faced with the often difficult trade-off between the benefits of innovative and costly drugs and the less expensive older options that may be less effective or have greater side effects.
It is ironic that a pharmacy benefit management company (PBM) like ESI is self-declaring itself as the Robin Hood of modern-day health care. After all, PBMs only negotiate and carry pharmaceutical costs, while not directly managing other components of a patient’s treatment, such as in-patient and out-patient therapies and drugs that fall under medical benefits.
Even just from a medical cost perspective, it requires a holistic medical view to responsibly evaluate trade-offs between drug expenses and longer-term medical expenses. Patients obviously have a strong interest in long-term clinical and health outcomes. PBMs by nature will be less motivated to fund life-extending treatments than fully integrated plans will.
For example, the increased cost of the new generation drugs for hepatitis C will result in lower rates of liver cirrhosis and hepatic cancer and will also reduce the cost of liver transplants. These considerations fall outside the perspective of a PBM, which only fund drugs. You can even argue that poor drug compliance due to side effects represents a cost saving to a payer like ESI. Many also doubt that discounts that are negotiated by ESI will really benefit patients; limitations in drug treatment options certainly will affect them.
Robin Hood? Probably not.