But the real heroes in the ‘battle’ to reduce what are always referred to as skyrocketing drug costs are people like Nicole who are denied access to new medicines in order to pad the profits of CVS and other PBMs:
Nichole, a 25-year-old living with Hepatitis C, was desperate when she reached out to WBZ-TV.
“A week ago, I didn’t feel any hope,” she told the I-Team.
She had been struggling with the disease since she was abducted four years ago. The fatigue and jaundice, plus the stigma made it hard to get on with her life.
Making matters worse, the man who victimized her had received a life-saving cure in prison.
Nichole was left only with multiple denial letters from her insurance company, Tufts Health Plan.
“Aside from the physical, emotionally, this has been horrible,” she told WBZ in January.
Nichole’s doctor prescribed it saying she was a perfect candidate. It would help rid her of the disease and move on. However, a full treatment of Harvoni is priced at a whopping $84,000. That’s $1,000 per pill. Tufts Health Plan denied Nichole coverage of the drug, saying she isn’t sick enough yet. “The insurance company wants me to be in Stage 3 liver scarring,” she said.
Let the record show that this denial comes from CVS, the hero of drug pricing critics. And the rationale for rationing Nicole is courtesy of our friends at the Institute for Clinical and Economic Review. These drug price watchdogs, as their acolytes in the media has hailed ICER, has recommended that HCV patients like Nicole be denied cures until there “is some evidence of liver fibrosis.” More on this media anointed (as well as health plan and Enron billionaire funded) arbiter of price and the value of a human life in a future post.
And don’t forget that CVS has an exclusive deal with Gliead to make it the only HCV drug on their formulary. But even then, you have to fail first or get liver damage to try another drug.
Nicole is one of the lucky ones. According to Camilla Graham, MD, assistant professor of medicine at Beth Israel Deaconess Medical Center in Boston. Every single Viekira Pak scrip she has written for her Medicaid patients has been denied. “Things aren't going so well, and Massachusetts, I will say, has the best access of any state. Our Medicaid doesn't have ridiculous restrictions,” she says. “I'm calling them restrictions, but it's really rationing. We're seeing rationing of care for hepatitis C like I've never seen in U.S. medicine.”
CVS’ chief medical officer, Troyen Brennan, said that without Sovaldi being introduced, the 11.8% growth might have been about 10%, and that this year’s spending growth would have remained at about 5%.
But wasn’t Solvadi going to increase premiums by 30 percent? Brennan co-authored a piece in JAMA in which he asserted. “ The simple math is that treatment of patients with HCV could add $200 to $300 per year to every insured American's health insurance premium for each of the next 5 years,"
That’s BS obviously. Even worse, it was BS used to justify rationing drugs and cutting exclusive deals with drug companies so that sick patients would have to beg for cure.
Meanwhile, the “fine-tuning” as Matt Herper happily describes is more like a blitzkrieg against access. As Adam Fein dryly notes:
Express Scripts has 66 products on its 2015 formulary exclusion list, compared with 48 in 2014. CVS Caremark’s 2015 list has 95 products, including 72 carryovers from the 2014 edition. Nostalgic readers will recall that CVS Caremark removed a mere 34 drugs from its 2012 standard national formulary. I guess there ain't no valley low enough, either.
Adam’s right. CVS and other PBMs haven’t reach their low point in limiting access, cutting deals and using ICER as a price fixing front in order to maximize the spread between the net cost of a drug (often up to 40 percent of average wholesale price) and how much they force patients to pay out of pocket for medicines that are right for them.
As Stacy Trooskin, MD, PhD, assistant professor in the division of infectious diseases and HIV medicine at Drexel University College of Medicine in Philadelphia points out: “I get a little bit concerned when we have exclusivity deals and none of these price cuts that the payer is receiving from the pharmaceutical company translate to ease of access.”
The decline in drug costs is a result of the increased success of PBMs extracting rebates and denying access. A Credit Suisse analyst report found that: “For 2014, our 20 company universe has shown net US drug sales of $202bn and reported total rebates of $98bn. We conclude that in 2014 US rebates rose 24% against just a 7% increase in net sales, reflecting continued formulary pressures. “
Which means that 2015 was a great year for PBMs because it was worse for patients.