Comparing the Two Main Prescription Drug Pricing Reduction Proposals

It seems like the Senate may—if Majority Leader Mitch McConnell (R-KY) does his job—be able to debate and vote on the Prescription Drug Pricing Reduction Act (PDPRA) of 2019 this Fall.

Not to be confused with the Prescription Drug Price Relief Act of 2019, which was introduced by Senator Bernie Sanders (D-VT), in January (and which gained little support), the PDPRA was a bipartisan piece of legislation, sponsored by Senate Finance Committee Chairman Chuck Grassley (R-IA) and Ranking Member Ron Wyden (D-OR). The full text is not yet available; PDPRA was created as a chairman’s mark, and has not been formally introduced (or available on the Congress.gov site). Interestingly, the bill was able to fend off attempts by other Republican members, notably by Senator Pat Toomey (R-PA), to defang it through the amendment process. On July 25, 2019, the proposal was passed by the Senate Finance Committee, with several reimbursement-based methods for improving utilization of biosimilars. This includes boosting the add-on payments for new biosimilars.

On September 19, 2019, Speaker Nancy Pelosi (D-CA) introduced the long-awaited House of Representative’s proposal (in outline form). The two bills contain several of the same provisions (see the Table) and may well set up a consensus around the final legislation, if passed in both chambers. However, the House bill does not offer incentives for increasing biosimilar uptake.

TABLE: Summary of Main Provisions of Drug Price Reduction Proposals

  PDPRA Speaker Pelosi’s Proposal*
Breadth Medicare only Medicare and Commercial
Use Medicare International Price Index? Yes Yes, as maximum negotiated price
Negotiated Drug Prices No Applies to up to 250 drugs (min, 25) that lack competition (including insulins); refusal to negotiate incurs penalties up to 95% of previous year’s gross sales of drug
Penalties for Price Increases Above Inflation Retroactive rebate on Part B drugs (not biosimilars) that have raised prices above inflation, beginning January 2021; mandatory rebates on branded Part D drugs with price increaseshigher than inflation Retroactive rebate on all Medicare Part B and D drugs that have raised prices above inflation since 2016
Limits on Medicare Pharmaceutical Cost Sharing $3,100 Out-of-pocket limit on drug costs for Medicare beneficiaries $2,000 Out-of-pocket limit on drug costs for Medicare beneficiaries
Biologic Reimbursement Establish a WAC add-on payment of up to ASP + 3% when ASP has not yet been established; biosimilars would be paid the lesser of WAC + 3% or ASP + 6% of the reference product No provisions
Biosimilar Incentives Add-on payment for Part B biosimilars would now be ASP + 8% for first 5 years of sale No provisions
Other Significant Provisions Exclude patient assistance coupon value from Medicare ASP calculations Not addressed
  Require drugmakers without Medicaid drug rebate agreements to report quarterly ASPs to HHS, on which reimbursements will be based Not addressed
  Require refunds be paid to HHS on any single-dose vial Part B drugs for unused amounts that exceed a threshold Not addressed
  Maximum ASP plus add-on payment that a provider may receive per year administering one drug is $1,000 Not addressed
  Website publication of aggregate price concessions (including rebates and discounts) on Part D drugs Not addressed
  Require manufacturer justification (publicly posted) for price increases based on certain minimums and thresholds Not addressed

*Based on Proposal Outline, as of Sept 19, 2019.

Although President Trump has indicated support for the overall theme of drug pricing reduction, he has not endorsed either bill or its specific combination of actions. The Republican opposition to the Senate’s PDPRA is likely to be heavy, and Senate GOP opposition to Speaker Pelosi’s bill will also be a difficult barrier, even without the President’s support.

If both bills can make it to the conference stage, the Administration may be able to claim that it has delivered on one of its campaign promises. Otherwise, the drug pricing reduction proposals will result in another dead end, similar to the drug rebate safe harbor appeal and drug patent reform.

Trump Administration Does About-Face on Drug Rebate Safe Harbors: Opportunity Lost for Biosimilar Competition

It seemed like the best opportunity biosimilar manufacturers had in a long time to gain a competitive foothold upon launch. Secretary of Health and Human Services Alex Azar had promised a repeal of the drug rebate safe harbor as a key component of the Trump Administration’s move to obtain lower drug prices. Today, the Administration reversed its course, leaving the biosimilar industry hanging in the balance.

drug rebate safe harbor
HHS Secretary Alex Azar

According to reports, Health and Human Services found itself between a rock and a hard place. If the drug rebate safe harbor was removed, Medicare part D premiums could rise (plans would compensate for lost rebate revenue by raising consumer costs). There was also no guarantee that lower prices would be passed on to consumers at the pharmacy. Loss of drug rebates would also place great pressure on pharmacy benefit managers (PBMs) to maintain or reduce net drug costs for their plan and employer clients. Accordingly, the removal of the drug rebate safe harbor was opposed by many stakeholders and not supported by enough interests (or with sufficiently influential lobbyists).

The result is a critical missed opportunity for increased access to biosimilars and their attendant savings. Drug rebates can only have value for payers if marketshare exists. In other words, a reference drug manufacturer who holds 100% marketshare before biosimilar launch can offer rebates on every prescription filled—that adds up to millions of dollars for individual PBMs and plans. A biosimilar drug without any marketshare at launch can offer a 50% rebate, but this is meaningless to the payer unless it captures significant marketshare immediately. Without rebates in the equation, biosimilars can compete against reference products on price alone, a much fairer fight for a new drug entering the fray.

Thus, the “rebate trap” will remain a barrier to access. This episode also makes one wonder which trial balloons given flight by the Administration will not come back to Earth. The idea of using the Federal Trade Commission to cut through patent thickets was recently floated and shot down by Texas Senator John Cornyn on the Senate Judiciary committee. We’ve heard about the plan to pin Medicare drug prices to either an international price index or to “most favored nations” pricing, or perhaps even both? Improving the utility of the Purple Book, to actually include useful information about key patent expirations and market exclusivity periods seems simple enough, but even this will take some doing. Interchangeability guidelines published in final form? Well, that should have been completed a couple of years ago.

Despite the approval of 21 biosimilars in the US, the industry does seem to be an awful lot to be worried about. Add in the looming concern in federal appeals court about whether the Affordable Care Act can withstand ongoing attacks concerning the individual mandate, which can then undercut the entire regulatory pathway for biosimilar approval. I know I’m not the only person shaking his or her head. The repeal of the drug rebate safe harbor was a real opportunity to turn the tide.

With Higher Prices, the Need to Promote Longer-Term Value of Pharmaceuticals

The keynote session at the Academy of Managed Care Pharmacy’s Nexus meeting this week aired notes of resistance and denial, resignation, and acceptance. This may sound familiar, especialAMCP logoly if frustration was substituted for actual grief, and closely reflects the process for dealing with the death of a close friend or relative. In this case, one could say that the dearly departed is pharmaceutical pricing rationality.

The panel discussion was in many ways a eulogy. Alan Weil, Editor-in-Chief, Health Affairs, moderated the service. The chief question at hand was whether we are willing or able to pay for innovative therapies that may cost a half-million dollars or more? Mr. Weil pointed out that apart from their cost, these new therapies (e.g., CAR-T) “fit poorly into our current payment model.”

Steve Miller, MD, Senior Vice President and Chief Medical Officer, Express Scripts, said that the answer is no. We are apparently not willing to pay for them, based on the hepatitis C treatment paradigm today. He noted that the antiviral treatments available today are highly curative. “Although hepatitis C treatments have come down in price, we, as a society, do not pay. We’ve treated only one third of the patients so far. And now, we’re challenged with a $1 million treatment. We need to change our mindset.”

Jane Barlow, MD, MPH, MBA, Senior Advisor, Massachusetts Institute of Technology Center for Biomedical Innovation, countered that in the end, “We will pay. The patients want these innovations. The question is really the sustainability.”

J.D. Kleinke, Medical Economist, agreed, saying that “We as a country demand access, and we demand progress. People will sue for it, have bake sales for it, to force the system to pay for it.”

“If the hepatitis C vaccine cost originally $10,000 per month and it was to be taken chronically, people would not worry much about paying for treatment, said Robert DuBois, Chief Medical Officer, National Pharmaceutical Council. The original price tag of $84,000 for a limited treatment course, however, did set a firestorm of controversy.

There also seems to be a different reaction when speaking to payers one to one, according to Dr. Barlow. She said that in private conversations, payers express less concern than in groups [or in the press]. “When we say we’re spending too much, we seem to be spending more,” she said.

Web image 1With new gene therapies and immunologic approaches, the pricing models and relatively few people treated will force payers and purchasers to take a different evaluation approach to value, said Dr. Kleinke. This may involve a longer view towards future productivity or “value capture.” With this concept, if a drug company charges $100,000 for an intervention that helps produce $1 million in productivity or additional benefit, the drug “captures” 10% of the value of the transaction.

Perhaps our ability to pay for them is a very different question. Until now, pharmaceutical pricing could be explained relative to other similar therapies or compared with the likely costs of future care avoided. It may be that future productivity gained, rather than medical costs avoided, may be a better framework for evaluating the pricing of these next generation interventions.