Where’s my money?

In an attempt to “take one for the team,” Express Scripts announced “it is introducing a novel formulary (aka Flex Formulary) to provide employers and health plans an opportunity to leverage changing dynamics to help lower their members’ out-of-pocket costs.” Groovy, but wait. According to Drug Channels, there are two possible roadblocks – Problem 1: Many plan sponsors are addicted to rebates and Problem 2: PBMs have rebate guarantees with their plan sponsor clients. “The economics of PBMs and plan sponsors can encourage the use of high-list/high-rebate drugs” and Express Scripts told Drug Channels that some of its clients are “addicted to rebate checks.” Give a hand to Express Scripts for trying something new. For one of the better Family Guy scenes go here and always remember to pay Stewie back (low volume recommended). Enjoy.

A merger “O.K.” with a slight delay

Not to be outdone by the Cigna-Express Scripts merger, CVS Health and Aetna’s proposed merger has been approved by the US Justice Department. The $69B (nice) deal combines Aetna’s insurance skills with CVS’s drug benefits management and nearly 10,000 pharmacy locations to create a healthcare behemoth. The deal will allow Aetna customers to seek less expensive medical services at those pharmacy locations, including CVS’s 1,000+ walk-in clinics which have served 25M patients since 2000.  To get the deal approved, Aetna had to sell all its standalone Medicare Part D plans. Otherwise, the merged company would have owned 30 percent of those drug plans—an unacceptable share to the DOJ. We’ll be interested to see how the new company competes with the similarly structured Cigna-Express Scripts in the coming years.

A merger “O.K.” with little delay

Cigna and Express Scripts have received their parents’ the Justice Department’s blessing to go ahead with their wedding merger. The health insurer and pharmacy benefit manager say they’re a good fit for each other since they’ll be able to share information about their customers’ medical expenses that will help them manage patient health better. But the announcement has got to sting a bit for CVS Health and Aetna, who have been waiting on DOJ approval for their merger since before the Cigna-Express Scripts deal was announced. Visual/meme representation of that here. You’ve gotta think that Amazon’s ever-threatening encroachment into the healthcare industry is driving some of these vertical mergers between health insurers and PBMs.

Drug spending in the US is… down?

Well, for some cohorts, yes, drug spending in 2017 was down. Holy schneikies. What’s more is that, according to the Express Scripts 2017 Drug Trend Report, drug spending increased by only 1.5% for their commercial plan sponsors and it declined for nearly half of commercial payers. For a really good synopsis of the report, go here. In what we can only assume will be a politically unpopular analysis, Drug Channels points out that specialty drug costs are not the problem because “Specialty unit costs grew by 3.2% for commercial payers, while utilization grew by 8.1%. In other words, spending increased because more people were treated, and more prescriptions were dispensed. That’s not a drug price problem.” Son of a … But it’s not all sunshine and roses, as 6.3% of people spent more than $1,000 out-of-pocket for prescription drugs in 2017. Sorry for the buzzkill.

Civil War: healthcare edition

The formula for rising healthcare costs in the US is filled with a bunch of pointed fingers lately. One finger is being pointed at drug maker Kaléo (no, not that Kaleo) by pharmacy benefit manager Express Scripts. They’re suing Kaléo over its price hikes on a heroin/painkiller overdose treatment. According to Express Scripts, these hikes triggered price protection rebates owed to Express Scripts, which total around $14 million—most of the lawsuit. The PBM has successfully sued larger drug companies like Horizon, so Kaléo may be at a bit of a disadvantage here. Especially since Express Scripts could use the extra cash to deal with the fingers pointed at it, including one $15B lawsuit by its (soon-to-be former) largest customer, the insurance provider Anthem.

2. The war on drug stores heats up

Recent power plays in the prescription drug industry make J.R. Ewing’s actions seem like child’s play. If you don’t track the specialty pharmacy market, you should. This is a $100B industry that is growing rapidly. Think high-priced drugs used to treat Hep C and Cystic Fibrosis. According to the New York Times, large PBMs might be trying to force out independent specialty pharmacies. In Alabama, BCBS recently told patients that they cannot have their prescriptions filled at CVS. This is a big deal. It means patients have to sever long-standing relationships with pharmacists, especially difficult with specialty indications. This is all part of an emerging trend to narrow networks. Look it up. You will be glad you did and you’ll be smarter.