Patients get caught in the middle of pricing

UnknowninsurerKEY TAKEAWAY: DTC marketing is meant to drive new Rx’s but insurers are having a bigger say about which drugs patients get.  Can the drug industry make peace with insurers or is it going to be a battle of war between profits, Wall Street and patients.

A patient with a nagging GI problem needs surgery to correct the problem, but her insurer makes her wait over six months while her health care provider tries other treatments that don’t work.  A patient, with high cholesterol, is prescribed Crestor but his insurance company tells his doctor that he first has to try generic statins before he can be prescribed Crestor.  Welcome to the new era of healthcare.

Vertex is hoping for approval of a new cystic fibrosis drug and although they haven’t announced a price yet, but J.P. Morgan predicts the company will charge a wholesale price of around $287,000 annually per patient.  Express Scripts Holding Co., the largest U.S. pharmacy benefits manager, says that price will overwhelm employer health plans. “We’re really hoping this product comes out at a much more affordable price, because the burden to payers is extraordinary,” said Express Scripts Chief Medical Officer Steve Miller.

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Can DTC marketing overcome what insurers dictate and is what insurers dictate always the best treatment recommendation? The answer to that is doubtful.  When Viagra comes off patent, for example, does anyone think insurers are going to pay $10-$12 a pill for Cialis?

How did this happen?  The drug industry is largely to blame with very high drug prices.  While insurers seem to be making healthy profits under the Affordable Care Act they can’t allow the drug companies to continue to introduce high priced drugs that drain company coffers. Some drug companies are working with insurers during drug development so they are more comfortable with the product efficacy and pricing model, but a company like vertex is in trouble because their Hep-C drug got shattered by new, more costly drugs and they need to turn a profit to survive.  One has to wonder why in the hell they even sank money into a product that would be obsolete so quickly?images-1

It would be interesting to learn what percentage of patients that request certain drug products are turned away because of their insurer.  It seems that not many drug sites have a list of approved insurers, but why should they try and help patients as opposed selling them on a drug that they can’t get?