It’s time to set 2025 priorities and action plans – an exercise I love to do — and this week’s caught my eye is a hodgepodge of things to consider.
Planning Woes. I’ve been wanting to write about the presidential candidates and what they might do in terms of health policy and pharmaceuticals if elected. But it has been a non-issue on the campaign trail. President Trump has walked back from his most favored nation proposals (tying prices in the United States to those in other countries) and Vice President Harris has supported increasing the number of drugs negotiated under the Inflation Reduction Act, but it isn’t a central focus. I was hoping the campaigns would give a better sense of what to expect in the next four years but the relative silence on pharma policy makes me a little nervous.
Book of No Good, Very Bad Ideas. On the other hand, the Congressional Budget Office (CBO) put out a report on drug price solutions that walks through the different ideas and their impact. A nice save-for-later if you’re doing policy strategy.
A Start. CBO also looked at anti-obesity medications and Medicare coverage. Cost? $35 billion over 10 years. I focused on the savings piece; I have a strong suspicion that CBO underestimated the potential savings. To be fair, it is moving target in a relatively new space. USC wrote a nice summary of it all. I am a little in awe of what we’re finding out about these drugs from weight loss to cardiovascular to curbing addiction. But it is true – assuming long term use (years) on the medicine may be a stretch. Real world data + time should get us closer to a more accurate savings numbers.
It’s here! My favorite snap-shot of the employer insurance market is out this week. Kaiser Family Foundation does a bang-up job of capturing the 151 million beneficiary space each year. Quick factoids for you – on average, employees are paying over $500/month for family coverage. Employers are paying the rest of the over $2,000/month in premiums. The types of coverage that people are enrolled in (conventional, PPO, HMO, high deductible) has been relatively steady since 2019. In terms of prescription drugs, we live in a tiered world (over 80% use 3 or more) and copayments win over coinsurance but less so when it comes to higher tiers (more expensive) drugs.
PBM Predictions. I respect what Mark Cuban is out there saying about the pharmacy benefit manager (PBM) space and its lack of transparency. He’s a great messenger for the talking points and, he’s right, he has way more influence as businessman Mark Cuban than he would inside the Administration. But why doesn’t anyone talk about how he owns one of the solutions to the problem he is solving for? It makes me think of the HVAC company who came out and said I needed a new HVAC and then came in with the highest quote. Did I really need a new HVAC or were they just prepared to sell me one? Could the old one be fixed? My hunch is that the truth is in between. We will have to fix the current PBM system we have and be more aware of what we’re paying for. And some of us will shift to a whole new way of buying some drugs (Cost Plus). Here is my big question – if we “solve” for the PBM transparency problem – how will they make squeeze money out of the system next? What’s the next trick up the sleeve?