At last the mass media have turned their attention to the reality of excessively high drug prices in the U.S.  It wasn't that reporters and editors, during the past several decades, failed to notice how drug prices here are double and triple those of other advanced countries.  In fact, for twenty years or more, they published news stories about seniors taking bus rides to Canada to buy their medications, even as some people regularly faced the dilemma about whether to buy food or drugs. But since drug ads provide a major revenue source for media outlets, mass journalism largely failed to treat the matter as a major, persistent social problem.  Instead, the stories about trips to Canada and rent-versus-drugs usually lacked useful context, instead appearing as quaint pieces of human interest or as quizzical parts of the passing fanfare. Recently the media have been running stories where health care analysts, physicians, administrators at provider networks and other observers eagerly discuss their respective ideas for curtailing drug prices.  Four recent approaches to the matter deserve some attention. The first was prompted by last week's announcement from Britain's National Health Service that the number of therapies its Cancer Drug Fund covers would be cut by 30% to contain unsustainable costs. Graphic by Bloomberg Business Week Cancer drugs stand in the front line of soaring drug prices.  As the United Nations predicts the number of people worldwide over age 65 will triple between 2010 and 2050, the older population will spike the incidence of age-related diseases such as cancer.  The WHO predicts a 70% increase in the number of cancer cases during the next 20 years. Global spending on cancer drugs already has more than doubled in the past decade, according to IMS, a pharma data collector. This led pharma consultant Bernard Munos to tell the Financial Times that "the cost of these drugs is not sustainable...[and] what is happening in the UK today will happen in America tomorrow.” Mr. Munos claims the best answer lies in ending Big Pharma R&D and outsourcing the function to smaller, nimbler biotechs and startups with lower expense levels. That sounds reasonable but it is unlikely to contain spiraling drug costs.  Big Pharmas are already moving in that direction by buying biotechs or making deals to subsidize research at the smaller companies.  The entire thrust of research across the range of specialty products in areas such as oncology, auto-immune diseases, and virology already involves research by university medical centers and small biotechs. Munos's suggestion fails entirely to get at the heart of the matter.  As leukemia specialist Hagop Kantarjian, at Houston's MD Anderson Cancer Center, told the Financial Times, "no amount of innovation can justify the doubling in average US prices over the past decade to more than $100,000. 'It is profiteering and greed,' he says." A second line of analysis proceeds by ignoring growing drug costs and, instead, recommends giving everyone a vastly more generous prescription drug plan. This month, in the American Journal of Public…

Why is this document important?  Healthcare marketers are aggressively pursuing new revenue streams to augment lower reimbursements provided under PPACA. Prescription drugs, particularly specialty, are key drivers in the growth strategies of PBMs, TPAs and MCOs pursuant to healthcare reform.  The costs shared below are what our pharmacy actually pays; not AWP, MAC or WAC. The bottom line; payers must have access to "reference pricing." Apply this knowledge to hold PBMs accountable and lower plan expenditures for stakeholders. How to Determine if Your Company [or Client] is Overpaying Step #1:  Obtain a price list for generic prescription drugs from your broker, TPA, ASO or PBM every month. Step #2:  In addition, request an electronic copy of all your prescription transactions (claims) for the billing cycle which coincides with the date of your price list. Step #3:  Compare approximately 10 to 20 prescription claims against the price list to confirm contract agreement.  It's impractical to verify all claims, but 10 is a sample size large enough to extract some good assumptions. Step #4:  Now take it one step further. Check what your organization has paid, for prescription drugs, against our pharmacy cost then determine if a problem exists. When there is a 5% or more price differential (paid versus actual cost) we consider this a problem.   Multiple price differential discoveries means that your organization or client is likely overpaying. REPEAT these steps once per month.   -- Tip --   Always include a semi-annual market check in your PBM contract language. Market checks provide each payer the ability, during the contract, to determine if better pricing is available in the marketplace compared to what the client is currently receiving.  When better pricing is discovered the contract language should stipulate the client be indemnified. Do not allow the PBM to limit the market check language to a similar size client, benefit design and/or drug utilization.  In this case, the market check language is effectually meaningless. Click here to register: "How To Slash the Cost of Your PBM Service, up to 50%, Without Changing Providers or Employee Benefit Levels." [Free Webinar]

CVS Caremark 2013 Drug Trend Report 10. The Cost of Specialty Drugs Is "Going Through The Roof" With No End In Sight 9. Specialty Distribution Networks Are Expanding To Allow for Greater Access And Control of Specialty Drugs 8. Biosimilars Are Coming; The First Is Poised For FDA Approval 7. Health Care, As A Whole, Is Evolving Into A Pay-For-Performance Marketplace 6. Growing Adaptation Of Data Analytics Will Improve Patient Outcomes 5. Poor Patients Continue To Flood The Specialty Space Through PPACA 4. As Drug Costs Go Up, Adherence Goes Down Thus Hospital Spend Increases 3. The Marriage Of PBMs And Specialty Pharmacy Continues To Strengthen 2. Specialty Drug Manufacturers Continue To Limit Distributors For Margin Protection 1. Cost Will Be Weighed Against The Outcome Not Hyperbole

Why is this document important?  Healthcare marketers are aggressively pursuing new revenue streams to augment lower reimbursements provided under PPACA. Prescription drugs, particularly specialty, are key drivers in the growth strategies of PBMs, TPAs and MCOs pursuant to healthcare reform.  The costs shared below are what our pharmacy actually pays; not AWP, MAC or WAC. The bottom line; payers must have access to "reference pricing." Apply this knowledge to hold PBMs accountable and lower plan expenditures for stakeholders. How to Determine if Your Company [or Client] is Overpaying Step #1:  Obtain a price list for generic prescription drugs from your broker, TPA, ASO or PBM every month. Step #2:  In addition, request an electronic copy of all your prescription transactions (claims) for the billing cycle which coincides with the date of your price list. Step #3:  Compare approximately 10 to 20 prescription claims against the price list to confirm contract agreement.  It's impractical to verify all claims, but 10 is a sample size large enough to extract some good assumptions. Step #4:  Now take it one step further. Check what your organization has paid, for prescription drugs, against our pharmacy cost then determine if a problem exists. When there is a 5% or more price differential (paid versus actual cost) we consider this a problem.   Multiple price differential discoveries means that your organization or client is likely overpaying. REPEAT these steps once per month.   -- Tip --   Always include a semi-annual market check in your PBM contract language. Market checks provide each payer the ability, during the contract, to determine if better pricing is available in the marketplace compared to what the client is currently receiving.  When better pricing is discovered the contract language should stipulate the client be indemnified. Do not allow the PBM to limit the market check language to a similar size client, benefit design and/or drug utilization.  In this case, the market check language is effectually meaningless. Click here to register: "How To Slash the Cost of Your PBM Service, up to 50%, Without Changing Providers or Employee Benefit Levels." [Free Webinar]

"Sticker shock" may be the best term to describe the malady that is hitting independent pharmacists. They arrive at work - mostly behind the prescription counters at small drugstores - and, when they turn on their computers, are shocked by sudden and drastic price increases for generic medicines. In November, one pharmaceutical vendor increased the price of a tube of prescription cream to treat athlete's foot by more than 800 percent. In April, the price of one generic antibiotic went from about 15 cents a capsule to more than $2.70 a capsule, an increase of more than 1,700 percent. "It is like a surprise, every day," said Doug Hess, a pharmacist who owns Doug's Family Pharmacy in Caernarvon Township. Brandon Wiley, who is head pharmacist and manager at Wiley's Pharmacy in East Hempfield Township, Lancaster County, said he once paid $20 or $30 for 500-tablet bottles of the antibiotic, Doxycycline, that he would use to fill many prescriptions. "Now, it is over $1,000 for the same bottle," he said. A lot of people buying prescriptions don't feel the financial hit - at least not immediately - because their prescription insurance plans require only a co-pay. But Robert Frankil, who lives in Montgomery County and owns an independent pharmacy in Bucks County, said the complex and confusing financial relationships that cloud the connection between drugmakers and drug consumers - involving vastly profitable companies called "pharmacy benefits managers" - affect the public at large. Frankil went to Washington in November to testify before a U.S. Senate hearing on the spikes in generic drug prices. "Eventually, there is a trickle down to everyone," he said in an interview. "When you look at the rate of drug increases in price compared to the rate of inflation, it is ridiculous." After the hearing, Sen. Bernie Sanders, a Vermont independent, issued a statement that said drug companies have seen an opportunity to make a lot of money and have seized the opportunity. "There is greed at work in the pharmaceutical industry," Sanders said. He and Rep. Elijah Cummings, D-Md., have introduced legislation that would require drug companies to reimburse Medicaid if they raise the prices of generic drugs more quickly than the rate of inflation. A spokesman for the Washington-based Generic Pharmaceutical Association, a trade group, responded to questions by referring to statements issued in November by association President and CEO Ralph G. Neas. "This legislation once again misses the forest for the trees," Neas said, referring to the Sanders-Cummings initiative. "In actuality, generic drugs continue to be a resounding success in lowering health care costs and benefiting patients. Indeed, generics saved $239 billion in 2013 - a 14 percent increase in savings from 2012 - and more than $1.46 trillion over the recent decade." Neas cited a report from Express Scripts, the largest pharmacy benefits management company, that showed that since 2008, the price of brand drugs has almost doubled, but the price of generic drugs has been cut roughly in half. Regardless, John Norton,…

Why is this document important?  Healthcare marketers are aggressively pursuing new revenue streams to augment lower reimbursements provided under PPACA. Prescription drugs, particularly specialty, are key drivers in the growth strategies of PBMs, TPAs and MCOs pursuant to healthcare reform.  The costs shared below are what our pharmacy actually pays; not AWP, MAC or WAC. The bottom line; payers must have access to "reference pricing." Apply this knowledge to hold PBMs accountable and lower plan expenditures for stakeholders.  How to Determine if Your Company [or Client] is Overpaying Step #1:  Obtain a price list for generic prescription drugs from your broker, TPA, ASO or PBM every month. Step #2:  In addition, request an electronic copy of all your prescription transactions (claims) for the billing cycle which coincides with the date of your price list. Step #3:  Compare approximately 10 to 20 prescription claims against the price list to confirm contract agreement.  It's impractical to verify all claims, but 10 is a sample size large enough to extract some good assumptions. Step #4:  Now take it one step further. Check what your organization has paid, for prescription drugs, against our pharmacy cost then determine if a problem exists. When there is a 5% or more price differential (paid versus actual cost) we consider this a problem.   Multiple price differential discoveries means that your organization or client is likely overpaying. REPEAT these steps once per month.   -- Tip --   Always include a semi-annual market check in your PBM contract language. Market checks provide each payer the ability, during the contract, to determine if better pricing is available in the marketplace compared to what the client is currently receiving.  When better pricing is discovered the contract language should stipulate the client be indemnified. Do not allow the PBM to limit the market check language to a similar size client, benefit design and/or drug utilization.  In this case, the market check language is effectually meaningless. Click here to register: "How To Slash the Cost of Your PBM Service, up to 50%, Without Changing Providers or Employee Benefit Levels." [Free Webinar]

Specialty drugs, used to treat complex illnesses such as cancer and hepatitis C, are in the spotlight, sparking discussion around how society will pay for high-cost therapies in the future. Last year, 70% of all medication approvals by the Food and Drug Administration (FDA) were for specialty drugs. Many more are in the pipeline. In this infographic, HRI explores how specialty drugs are impacting the US healthcare system now and in years to come. Specialty medications include injectable and noninjectable drugs that are typically used to treat chronic, complex conditions and may have one or more of the following qualities: frequent dosing adjustments or intensive clinical monitoring; intensive patient training and compliance assistance; limited distribution; and specialized handling or administration. For this publication, specialty drugs have been defined as those listed in the specialty drug list for CVS Caremark. Drugs in this list were identified within comprehensive drug sales data sourced from EvaluatePharma. This data forms the basis of the categorization of total drug sales into specialty and traditional drug sales for 2013 and projected drug sales in 2020. The percentage of sales labeled as specialty were assumed to remain constant within each therapeutic category (e.g. Cardiovascular, Dermatology, Respiratory) from 2013 to 2020, notwithstanding economic factors. Projections into 2020 rely on prescription drug sales growth predicted by CMS National Health Expenditure data to account for economic factors and legislative factors such as the Affordable Care Act. Total prescription drug costs by payer and by medical condition were calculated using data from the Medical Expenditure Panel Survey (MEPS). Drug data from MEPS cover retail prescription drug expenditures. No over-the-counter medication sales are included, nor are prescription drugs used during hospital visits, outpatient visits, or office-based provider visits. The percentage of specialty drugs within each therapeutic category calculated using the EvaluatePharma dataset was mapped to the medical conditions utilized by MEPS. This allowed HRI to weight specialty expenditures by payer and by condition. Expenditures by payer means the outlays for a particular party (i.e. Medicare or out of pocket by the consumer). It does not mean expenditures by everyone with a particular type of insurance. For one condition category (the "hemorrhagic, coagulation, and disorders of white blood cells" category), there was not enough information in the MEPS data to measure drug spending by payer. Thus for this category, PwC assumed the average distribution of drug spending by payers. © 2014 PricewaterhouseCoopers LLP, a Delaware limited liability partnership. All rights reserved. PwC refers to the United States member firm, and may sometimes refer to the PwC network. Each member firm is a separate legal entity.

Why is this document important?  Healthcare marketers are aggressively pursuing new revenue streams to augment lower reimbursements provided under PPACA. Prescription drugs, particularly specialty, are key drivers in the growth strategies of PBMs, TPAs and MCOs pursuant to healthcare reform.  The costs shared below are what our pharmacy actually pays; not AWP, MAC or WAC. The bottom line; payers must have access to "reference pricing." Apply this knowledge to hold PBMs accountable and lower plan expenditures for stakeholders.  Note: This document is updated weekly to reflect changing prices and new products. Did you know that pharmacies (and PBMs) often negotiate discounts on prescription drugs which aren't reflected in AWP, WAC or MAC prices? The only way to be sure you're receiving these discounts is to gain access to invoices. How to Determine if Your Company [or Client] is Overpaying Step #1:  Obtain a price list for generic prescription drugs from your broker, TPA, ASO or PBM every month. Step #2:  In addition, request an electronic copy of all your prescription transactions (claims) for the billing cycle which coincides with the date of your price list. Step #3:  Compare approximately 10 to 20 prescription claims against the price list to confirm contract agreement.  It's impractical to verify all claims, but 10 is a sample size large enough to extract some good assumptions. Step #4:  Now take it one step further. Check what your organization has paid, for prescription drugs, against our pharmacy cost then determine if a problem exists. When there is a 5% or more price differential (paid versus actual cost) we consider this a problem.   Multiple price differential discoveries means that your organization or client is likely overpaying. REPEAT these steps once per month.   -- Tip --   Always include a semi-annual market check in your PBM contract language. Market checks provide each payer the ability, during the contract, to determine if better pricing is available in the marketplace compared to what the client is currently receiving.  When better pricing is discovered the contract language should stipulate the client be indemnified. Do not allow the PBM to limit the market check language to a similar size client, benefit design and/or drug utilization.  In this case, the market check language is effectually meaningless. Click here to register: "How To Slash the Cost of Your PBM Service, up to 50%, Without Changing Providers or Employee Benefit Levels." [Free Webinar]  

We know more patients than ever are covered by health insurance. We know emerging technologies, consumer demand and economic pressures are shifting healthcare into new models — models that will engage patients and put them back at the center of care. But how much will these forces noticeably change the healthcare landscape this year? PricewaterhouseCoopers' (PwC) Health Research Institute surveyed 1,000 U.S. adults, experts and clients to find out. They took a pulse on the top health industry issues for the coming year and presented their findings in a webinar last Thursday.  Here are the top 10 issues of 2015. 1. Do-it-yourself healthcare. This year, the intersection of consumer desire and technological advancements will put "D.I.Y. healthcare" at the top of the agenda, PwC predicts. Increasingly, consumers are taking charge of more of their own care. Technology companies are ready to help this happen with the development of apps and mobile devices to track health metrics such as vital signs, medication adherence or even urinalysis. Nearly half of physician respondents said they would be comfortable using data from a mobile device to determine if a patient should be seen in person or prescribed medication, and 90 percent felt the apps and mobile devices would be important to their practice in the next five years, according to PwC's HRI. 2. Making the leap from mobile app to medical device. The mhealth app space is getting more and more crowded. The FDA will likely review more mhealth apps this year than ever before. Regulatory approval could give some apps a competitive edge in a crowded sector. The rush of new apps also means consumers will need a way to sort through all the available tools. 3. Balancing privacy and convenience. Approximately five million patients had their personal records compromised from data breaches last summer alone, Mr. Isgur says. These EHRs, which offer personal, medical, financial and insurance information, can go for up to $1,300 on the black market. Yet as healthcare organizations strive to make data private, they must also consider their consumer, who could benefit from convenient data access. The healthcare industry can learn a lot from the financial and retail sectors on how to balance convenience and privacy with data. Collaborations with experts across industries may help healthcare organizations develop better security strategies. 4. High-cost patients spark cost-saving innovations. There is a very, very small percentage of people that cost our health system a lot of money. The sickest 1 percent of patients generates 20 percent of U.S. healthcare spending and dual eligibles are especially costly. We also know there's a laser focus in most healthcare organizations to try to reduce costs. To do that, many organizations are trying to look at those populations and develop innovative care models. This year we will likely see health systems employ a variety of strategies, including delivering care in new settings, through telehealth and retail clinics, high-tech solutions like wearables and apps, and low-tech solutions like making sure diabetic patients have refrigerators to store…

Why is this document important?  Healthcare marketers are aggressively pursuing new revenue streams to augment lower reimbursements provided under PPACA. Prescription drugs, particularly specialty, are key drivers in the growth strategies of PBMs, TPAs and MCOs pursuant to healthcare reform.  The costs shared below are what our pharmacy actually pays; not AWP, MAC or WAC. The bottom line; payers must have access to "reference pricing." Apply this knowledge to hold PBMs accountable and lower plan expenditures for stakeholders.  Note: This document is updated weekly to reflect changing prices and new products. Did you know that pharmacies (and PBMs) often negotiate discounts on prescription drugs which aren't reflected in AWP, WAC or MAC prices? The only way to be sure you're receiving these discounts is to gain access to invoices. How to Determine if Your Company [or Client] is Overpaying Step #1:  Obtain a price list for generic prescription drugs from your broker, TPA, ASO or PBM every month. Step #2:  In addition, request an electronic copy of all your prescription transactions (claims) for the billing cycle which coincides with the date of your price list. Step #3:  Compare approximately 10 to 20 prescription claims against the price list to confirm contract agreement.  It's impractical to verify all claims, but 10 is a sample size large enough to extract some good assumptions. Step #4:  Now take it one step further. Check what your organization has paid, for prescription drugs, against our pharmacy cost then determine if a problem exists. When there is a 5% or more price differential (paid versus actual cost) we consider this a problem.   Multiple price differential discoveries means that your organization or client is likely overpaying. REPEAT these steps once per month.   -- Tip --   Always include a semi-annual market check in your PBM contract language. Market checks provide each payer the ability, during the contract, to determine if better pricing is available in the marketplace compared to what the client is currently receiving.  When better pricing is discovered the contract language should stipulate the client be indemnified. Do not allow the PBM to limit the market check language to a similar size client, benefit design and/or drug utilization.  In this case, the market check language is effectually meaningless. Click here to register: "How To Slash the Cost of Your PBM Service, up to 50%, Without Changing Providers or Employee Benefit Levels." [Free Webinar]