Tag Archives: Merck

A Test Case on Sanity of Drug Prices

In both traditional healthcare and pharmaceuticals, the phrase “value-based purchasing” is all the rage. Rightfully so, we want to spend our precious healthcare dollars on the care that is most valuable. In other words, we want to pay for care and drugs that are effective and not pay for those that aren’t. Like everything else, the shortest path to value is a truly competitive market. The gorilla in the room is that healthcare, and especially pharmaceuticals, severely lack this fundamental capitalist feature that we have benefited greatly from.

American healthcare dwells in never-never land. We have neither explicit price controls through regulation nor implicit controls through a functional market, resulting in the worst of all possible worlds: a system that’s entrenched, opaque and dysfunctional. It gets worse when we narrow our focus on the drug market. We don’t even understand what it is that we are purchasing because buyers neither spend much time understanding drug effectiveness in the real world nor tie effectiveness to payment. Instead, in an attempt to save dollars, employers, health plans and the government have turned to intermediaries, pharmacy benefit managers, to manage the problem on their behalf. PBMs’ efforts to manage pharmacy costs rely on typical buzzwords like “formulary management,” “prior authorization” and “step therapy.” And PBMs are, as Bloomberg News explains, “the middlemen with murky incentives behind their decisions about which drugs to cover, where they’re sold and for how much.”

See also: 9 Key Factors for Drug Formularies  

This leads us down an unintelligible labyrinth of perverse financial incentives, with zero transparency for the payer or patient on the actual costs, alternatives for therapy and individual outcomes. That’s a problem especially in specialty pharmacy, the fastest-growing sector of pharmacy spending. Only a few years ago, specialty drugs composed a reasonable-sounding 10% of our overall drug spending. Last year, it bloated to 38%, and by 2018 it will be an astounding 50%, which is an increase of $70 million a day!

Contrary to what we often think, there are better options even for many specialty drug therapies. Mavyret, manufactured by AbbVie, is the first example of a new brand name Hepatitis C drug that is actually better for patients and costs far less since Sovaldi hit the market at a price point of $1,000 a pill (never mind that you can purchase it for $4 per pill in India). Eighty percent of patients with Hep C can do an eight-week course versus alternatives manufactured by companies like Gilead and Merck, which generally require 12 weeks. Mavyret is the only drug that works for genotype’s 1-6 and has a list price that is less than half of what competitors charge, even after factoring in middleman shenanigans such as rebates. The final cost to cure a patient of Hep C is approximately $26,000. If that sounds high, consider that specialty medications for chronic conditions such as psoriasis are now $60,000 to $120,000 or more per year.

If you’re like most payers, our current system locks you into paying more for drugs for your members that are less effective than proven, cheaper alternatives like Mavyret. For starters, your PBM may only provide more expensive drugs on its formulary because of large manufacturer rebates, the majority of which they retain. Formulary decisions, of course, are not based on what is most effective for the patient or cheaper for you, the payer.

We feel the financial pain of this broken system every day, but it doesn’t have to be this way. Two decades ago, the internet revolution made the travel agency obsolete for most Americans. Uber and Lyft have done the same to parts of the transportation industry, and Amazon continues to do this to many others. What have these disruptive innovations taught us? That we might, in fact, be able to make better decisions ourselves, without non-value-added middlemen. It is time for this type of disruptive innovation to hit the pharmacy world.

Today’s system focuses on controlling suppliers through PBMs, which in reality just limit our choices and prevent the functioning of a real market. Instead, if we were to focus on value, we could use patient data to give us an objective understanding of whether the patient was getting the right outcome at the right price. This scenario represents an opportunity for better health outcomes and savings compared with the status quo. Here’s the catch: To enter this world, we have to start saying “no” to the current “travel agents” and their obsolete model.

See also: Opioids: Invading the Workplace  

In many ways, Mavyret is like the canary in the coal mine. If this drug isn’t successful – we know it is better for the patient, more effective and costs less – what signal does this send pharmaceutical companies? Don’t bother discovering better drugs that cost less because they won’t sell!

We salute AbbVie for doing what is right for patients and payers. America is the leader in driving innovation and investment in new drug discovery, and our inability to make the right choice not only reduces therapy choices for millions of Americans and their physicians but also for billions of others around the world who depend on us for leadership. Now is the time for payers to demand a functional market and stop overpaying for less effective therapeutic options.

Why Trump’s Travel Ban Hurts Innovation

Silicon Valley exports technology and imports the world’s best talent. That is how it has helped grow America’s economy and boosted its competitive advantage. President Trump’s executive order banning immigrants from some Muslim countries sent shock waves through the tech industry over the weekend because it was a loud and clear message to the world that America’s doors are now closed, and that xenophobia and bigotry are the new rules of law.

It is no wonder that executives at almost every major technology company, including Alphabet, Facebook and Apple, have made statements defending immigrants and distancing their companies from the president. These companies are worried about their survival and the future of the country.

Let there be no doubt that immigrants are essential to our economic present and future. These newcomers start a disproportionate number of U.S. businesses, particularly in advanced technologies. Immigrants and foreign-passport holders occupy a growing majority of places in graduate education programs in computer science, mathematics, physics and other hard sciences. They play an outsize role in U.S. research and innovation.

See also: An Open Letter to the Trump Administration  

A 2012 research paper I co-wrote, “America’s New Immigrant Entrepreneurs: Then and Now,” documented that 24% of U.S. engineering and technology startup companies and 44% of those based in Silicon Valley were founded by immigrants. My research also determined that immigrants contributed to more than 60% of the patent filings at innovative companies such as Qualcomm, Merck, General Electric and Cisco Systems. And surprisingly, more than 40% of the international patent applications filed by the U.S. government had foreign-national authors.

Study after study has found that immigrants are more likely to start job-creating businesses, not only in tech but across the economy. In 2014, 20% of the Inc. 500 companies had immigrant founders. That’s despite immigrants accounting for less than 15% of the U.S. population. According to research by economist Robert Fairlie for the Small Business Administration, immigrants are more than twice as likely to found businesses as non-immigrants, and 7.1% of immigrant-founded businesses export their products outside the U.S. as compared with only 4.4% of non-immigrant-founded businesses.

Clearly, blocking the path of immigrants into the U.S. cuts off the exact economic growth serum that has made America great. Creating an atmosphere where immigrants are fearful and uncertain about their future will reduce their incentives to open businesses here and stay. This is becoming even more so as other countries increasingly court educated immigrants and entrepreneurs. Those who support the president’s executive order say that the intent is to block people from countries where terrorism is sourced. But it’s not so simple.

By blocking entrance based on passport or country of birth rather than objective criteria, the executive order paints all immigrants from those affected countries and possibly dual passport holders with the same scarlet letter. What if the next Mark Zuckerberg happens to be Iranian? Or if an Einstein happened to be born in Libya? Let’s not forget that Steve Jobs’s father was Syrian — and he would have been banned from entering the U.S. under Trump’s dictate.

Yes, it is true that the affected countries are not the largest sources of immigrant entrepreneurs. But setting a precedent like this can mean that a politician can use this weapon against other countries that have become critical in supplying talent to fuel U.S. innovation. What if a frustrated president elected to block immigrants with Mexican, Chinese or Indian passports? The scenario, totally unthinkable a few months ago, is today entirely plausible.

In my 2012 book, “The Immigrant Exodus: Why America Is Losing the Global Race to Capture Entrepreneurial Talent,” I documented the stories of numerous immigrant entrepreneurs who were forced to leave the country because of shortages of skilled immigrant visas, called green cards. It wasn’t that we didn’t want these people here; American politics was caught in a political quagmire on skilled immigration. As a result, the country began suffering a brain drain, with highly skilled foreign-born doctors, engineers and scientists returning home.

With this executive order, Trump has made it clear that immigrants will have to worry about being singled out even after they have become lawful permanent residents; that their religion and place of birth may be the deciding factor in whether they are allowed to reenter the U.S. after going abroad. This will no doubt turn the trickle of skilled workers permanently leaving the country into a flood. Entrepreneurs who had wanted to come here will have now second thoughts.

See also: What Will Trump Mean for State Regulation?  

Whether or not the courts uphold the legality of the executive order, the damage has been done. Already, the number of billion-dollar technology startups, commonly called “unicorns,” that are located outside the U.. has been increasing dramatically. Fifteen years ago, almost all were in the U.S., while today 86 of the 191 unicorns are in countries such as China and India. We can expect this trend to accelerate because the Trump administration has just added fuel to the fire of innovation abroad and handicapped our own technology industry.

fat tax

Should You Announce How Fat Workers Are?

A shockingly serious proposal has been floated to first persuade (and later possibly compel) publicly traded companies to disclose to shareholders quite literally how fat their employees are.

Also, how much they drink, how well they sleep and how stressed and depressed they are.

This proposal, advocating what is known as a fat tax, shouldn’t even merit a discussion among rational businesspeople, and yet here we are, discussing it. Even Harvard Business Review (HBR) is discussing this.

Why? Because the well-financed, well-organized cabal behind this fat tax proposal include corporate names like Johnson & Johnson, PepsiCo, Humana, Merck, Novo-Nordisk and Unilever. The leader of this group is a South African insurer called Discovery Health.

If you guessed that any critique written by me would also implicate Ron Goetzel, you would be correct. Despite having now himself admitted that most wellness programs fail, he is the one justifying this entire scheme by claiming that wellness programs increase stock prices — even though they don’t. We’ve already offered a completely transparent analysis to the contrary.

He also made a rookie mistake in his own analysis. The stock prices of companies in his study diverged greatly in both directions from the averages, and he didn’t rebalance existing holdings annually. It’s simple compounding arithmetic. Suppose the stock market rises X% a year. If every stock in your portfolio increases at that rate, you’ll match the averages. However, if half your stocks increase 2X% a year while the other half don’t appreciate at all, and you don’t rebalance, you’ll beat the averages. Simply by doing nothing.

Goetzel’s study appeared right before the fat tax proposal was floated at Davos. No coincidence here — Discovery Health (the sponsor of the Vitality Institute) cites the study as a basis for wanting shareholders to “pressure” companies into disclosing the number of fat employees they have. And the more fat employees a company has, the more shareholders will insist on wellness programs, thanks to this study. Johnson & Johnson and Discovery both sell wellness programs, while Merck and Novo-Nordisk sell drugs for various wellness-related conditions.

We urge reading the HBR link in its entirety to see why a fat tax would be even worse than it sounds. Some highlights:

Most importantly, though – and you don’t need Harvard to learn this – it’s just not nice to stigmatize employees for their weight or other shortcomings unrelated to job performance. Basic human decency should have been taught to this cabal a long time ago.

We’ve pointed out many times in ITL that these wellness people were absent the day the fifth-grade teacher covered arithmetic. This proposal suggests that they were also absent the day the kindergarten teacher taught manners.

Radical Thought on End-of-Life Care

Pull up your drink and relax – you’re in for a deeper read. Thanks in advance for your eyes and time. Read on …

Here, I subscribe to the Elon Musk school of applying “first principles” to problem solving. I like to call this one my “Big W.” It has the potential to save tens to hundreds of billions of dollars annually, as well as provide solutions for other challenges we have outside of healthcare.

[Note: “Big W” comes from one of my favorite movies – if you know it, feel free to let me know. Chime back. Let’s just say a “Big W” is something so obvious many people simply pass right by. Often, value comes from finding and digging deeper.]

https://www.youtube.com/watch?v=r97Nv8N7-mI

OK, let’s get the scary numbers out of the way and frame the situation.

Numbers: According to the latest government statistics, private health insurers, Medicaid and Medicare collectively pay nearly $2.7 trillion annually to doctors, hospitals and other healthcare services. There is $53 trillion in Medicare and Medicaid unfunded liabilities. Mind you, expectations call for these numbers to rise considerably.

Players: On one side, we have services and products, including health insurers, doctors, medical services, hospitals and big pharma. On the other side, we have consumers, which are self- and fully insured companies, private pay citizens and individuals who receive state or government benefits.

Problems: Our healthcare system is for-profit, with publicly owned companies in different sectors, with shareholders, with funds held by current and future retirees and with massive numbers of employed individuals.

So, which companies willingly lower their charges to let customers keep more money to afford growing healthcare costs? Aetna, Merck, HCA? If they do lower their revenues, what happens to their stocks? Do people continue to hold? If not, how does that affect employment in the respective healthcare sectors?

The latest stats show that nearly 35% (78.6 million) of U.S. adults are obese. Obesity leads to heart disease, stroke, type 2 diabetes and certain types of cancer, which together are some of the leading causes of preventable death. About half of all adults – 117 million people – had one or more chronic health conditions. One in four adults had two or more chronic health conditions. Just think about the magnitude of this.

Do you honestly believe Americans are going to change their poor eating and exercise habits en masse and in a reasonably short term? Do you really expect the majority of obese individuals to take action to lose their excessive weight?

The reality is that we have a connected group of self-serving and self-centered individuals, businesses and political leaders, none of whom are willing to make sizable efforts to fix our healthcare system. Add in the massive marketing from food and beverage companies (sodas and alcohol), as well as fast-food restaurants that appeal to a majority of Americans who have little in the way of savings. That all spells a continuing downward spiral for our country’s healthcare costs and future affordability.

Enter the Big W

The Big W is the creation of what I call the “transition plan.” This starts with the revelation that a mere 6% of Medicare patients who die each year make up an astounding 27% to 30% of all Medicare costs. This accounts for nearly $200 billion in outgoing payments. According to statistics ​provided ​from the Center for American Progress fellow Ezekiel Emanuel and the latest CMS report on ​our 2014 ​national health expenditures (NHE), ​we add in another $250 billion for end-of-life care ​on those ​covered under Medicaid and private insur​ers. ​In all, that is nearly a half-trillion dollars per year, which plays, I believe, a very important role in our healthcare crisis.

The “transition plan” starts with an understanding that those insured individuals who will die in the next 12 months are, in a sad way, a monetary commodity for medical professionals, hospitals, big pharma and medical services/products companies.

Many of these individuals will die with little to no net worth. Since 1989, the proportion of those older than 75 with mortgage debt has quadrupled. Many seniors have large amounts of debt because of high medical bills, long-term care and dwindling retirement savings. In addition, credit card debt for seniors is larger and is rising faster than for the younger generations.

Let’s also not forget that many “last year” patients are people who are not senior citizens. Some come from the nearly 47 million Americans living in poverty or from the working, lower- to middle-income earners. While a portion of this population has life insurance, the industry reports that, of all U.S. adults, only 60% carry any level of coverage at all, and that our country is underinsured for life insurance by nearly $15 trillion.

We’ve extended life, and that is a noble task, but ask a chronically ill person or even an elderly person what they think about being kept alive for as long as possible. Those who are suffering recognize the importance of dying with dignity, instead of slowly wasting away through a myriad of medical appointments, drugs, therapies, surgeries and lab tests.

Here’s where the transition plan begins. It’s a system where health payers identify terminal patients or those who are highly likely to become terminal patients and willingly choose to forego payment for most related medical services. In return, they receive a guaranteed tax-free, single-windfall payment. The payment constitutes a large portion of what would have been paid out to the medical community.  

Take Charles Smith, a 68-year-old man who has been diagnosed with Stage 3B lung cancer. The average case has a 95% chance of death. Let’s estimate that between chemotherapy, radiation, lab tests, doctor visits, home health, costly medications, pulmonary therapy and several possible surgeries, a typical health payer can expect to reimburse between $345,000 and $375,000.

The health payer, ABC Insurance Co., receives the patient’s initial diagnosis on a medical claim. It’s flagged – the case is passed to the company’s medical management department. Once substantiated with medical records, the health payers’ actuaries set an estimated value of $350,000 on the case.

Now, the health payer gets in contact with the patient and presents the offer for the transition plan. The letter would state the following:

  • That, with the current diagnosis, the payer is offering the opportunity for the beneficiary to participate in the offer.
  • That the program is voluntary. If the beneficiary does not choose it, nothing will change with his current health coverage.
  • That, if the offer is accepted, the payer will send a one-time, tax-free, non-refundable payment to Mr. Charles Smith for $150,000.

Once the insurer makes the payment, the following would occur:

  • The health payer would no longer be responsible for payment for any treatment or services, directly or indirectly related to the chronic condition. All such conditions would be clearly identified in the Transition Plan Agreement.
  • The insured could continue to see medical providers and have them bill services to the health payer, so long as such conditions are separate from the main diagnosis and other listed conditions. However, payments for any future medical services billed, in keeping with company policy, must be determined to be medically necessary.
  • The insurer would continue to pay, on an as-needed and medically necessary basis, any palliative or “pain management” care associated with the main condition. This would not include hospitalization, therapy, home health or premium-brand medications.

What has just happened is a unique meeting of the minds between poor to middle-class dying Americans and the health insurance industry. In giving insureds the option to be financially compensated, health payers shift payments from the medical establishment back to individuals who are taking clear control of their lives.

In this specific case, corporate or private insureds receive back a large portion of the $200,000 cost savings in the form of reduced premiums, perhaps mandated by government to certain levels based on certain savings points. Naturally, for self-insured entities, the savings would flow back to the company or organization.

Imagine Mr. Smith having less than $5,000 of total savings and no insurance.  He is divorced, yet he has two children who are also in the lower income class.  While $150,000 of tax-free money is not millions, it could make a difference to that family and perhaps their ability to afford healthcare, a home or even college.

Without the transition plan, Mr. Smith might struggle to pay his remaining debts and have no money left over for funeral expenses. With the transition plan, he might take, or at least send, his two kids and their families on a trip around the world. Perhaps he would choose to contribute to several 529 plans for the education of his grandchildren.  He could also choose to give to charities, political groups or churches or even share with his most beloved friends.

The transition plan is the patient’s choice. If the patient is mentally unable to make a choice, she may default to the normal relationship with the health insurer, or the decision could shift to her immediate family or appointed surrogate. 

Public payers, private health insurers and corporations that pay for their own health benefits will now have the ability to help others make the transition and perhaps leave better legacies. Nothing puts a smile on someone’s face, especially in times of stress and depression, quite like when they give and get to see others enjoy their gifts.  Contrast this transaction with the same money going into medical and drug house pockets, leading to a continual raise of everyone’s plan premiums and a decrease in savings.

Who are the financial losers here? End-of-life medical services including chemotherapy, radiation, imaging, testing, surgeries, therapies, medical equipment sales and home health services.

The transition plan may not be the entire answer for our growing healthcare crisis and spiraling costs. Certainly, it is not going to be the choice for those who are dying and have plenty of savings to pass on to their loved ones or charity; nor will it be the choice for those who want to fight their diseases to the very end.

However, for a large majority of Americans who don’t have the assets to leave but recognize their value per historical healthcare payments to providers, the transition plan could be a useful measure. It would effectively allow them to stake a claim toward money normally ending up in the pockets of medical service professional  for cases not often resolving positively.