Abstract
Since passage of the Affordable Care Act (ACA) in 2010, US stakeholders are increasingly being held accountable for the value of healthcare services and drugs administered to patients. Pharmacoeconomic analyses offer one method of demonstrating a product’s value, yet there is a lack of resources specific to US drug costs relevant to each stakeholder. The aim of this study was to review current US drug costs (post-ACA). A literature review aimed at finding evidence on outpatient prescription drug costs was performed using the following sources: PubMed, governmental agencies, news websites, the Academy of Managed Care Pharmacy (AMCP) website, and Google Scholar. Articles were limited to those published in the years “2010–2016” and the “English” language, and those that described drug acquisition costs, reimbursement costs, and rebates or discounting for Medicare, Medicaid, and commercial payors. The Drug Cost Focus Group (DCFG) was convened to supplement the literature review; the DCFG provided their expertise on US drug costs and emerging issues affecting drug costs. ACA legislation increased drug rebates for manufacturers participating in the Medicaid Drug Rebate Program. Acquisition costs commonly referred to in the literature include the wholesale acquisition cost and average manufacture price. Drugs reimbursed by Medicaid are currently based on the actual acquisition cost and ACA-Federal Upper Limit. Evidence suggests that reimbursement methods in the public market are varied. Current gaps in the literature regarding commercial insurers’ drug costs (post-ACA) present barriers to the application of relevant drug costs to pharmacoeconomic analyses.
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References
Shi L, Singh D. Delivering health care in America. 6th ed. Burlington: Jones & Bartlett Learning; 2015.
Kaiser Permanente. Our history. 2016. https://share.kaiserpermanente.org/article/history-of-kaiser-permanente/. Accessed 27 Jul 2016.
Source book of health insurance data, 1999–2000. Washington: Health Insurance Association of America; 1999.
Enthoven AC, Fuchs VR. Employment-based health insurance: past, present, and future. Health Aff (Millwood). 2006;25(6):1538–47.
Blumenthal D. Employer-sponsored health insurance in the United States—origins and implications. N Engl J Med. 2006;355(1):82–8.
McDonnell K. History of health insurance benefits. Employment Benefit Research Institute; 2002. https://www.ebri.org/publications/facts/index.cfm?fa=0302fact. Accessed 27 Jul 2016.
Employer Health Benefits Survey. The Kaiser Family Foundation; 2013. http://kff.org/private-insurance/report/2013-employer-health-benefits/. Accessed 27 Jul 2016.
Medicare.gov. Your Medicare coverage: prescription drugs (outpatient). 2016. https://www.medicare.gov/coverage/prescription-drugs-outpatient.html. Accessed 27 Jul 2016.
Boukus ER, Carrier ER. Americans’ access to prescription drugs stabilizes, 2007–2010. Tracking report. Center for Studying Health System Change. 2011 Dec; No. 27. http://www.hschange.org/CONTENT/1264/1264.pdf. Accessed 24 Aug 2016.
Levinson DR. Replacing average wholesale price: medicaid drug payment policy. Department of Health & Human Services, Office of Inspector General; 2011. OEI-03-11-00060. http://www.oig.hhs.gov/oei/reports/oei-03-11-00060.pdf. Accessed 27 Jul 2016.
Wilke RJ. Beyond AWP… way beyond. Value Health. 2010;13(1):1.
Anderson L. Average wholesale price (AWP) as a pricing benchmark. 2014. https://www.drugs.com/article/average-wholesale-price-awp.html. Accessed 18 Oct 2016.
Settlement of conspiracy case forces major restructuring of prescription drug-pricing system. Prescription Access Litigation; 2006. http://www.dc37.net/news/newsreleases/2006/PALdrugpricing.pdf. Accessed 27 Jul 2016.
Curtiss FR, Lettrich P, Fairman KA. What is the price benchmark to replace average wholesale price (AWP)? J Manag Care Pharm. 2010;16(7):492–501.
Levinson DR. Medicaid drug price comparisons: average manufacturer price to published prices. Department of Health & Human Services, Office of Inspector General; 2005. OEI-05-05-00240. http://www.oig.hhs.gov/oei/reports/oei-05-05-00240.pdf. Accessed 30 Jul 2016.
Department of Health and Human Services. Medicaid program; covered outpatient drugs; final rule. Federal Register. 2016 Feb 1. https://www.gpo.gov/fdsys/pkg/FR-2016-02-01/pdf/2016-01274.pdf. Accessed 27 Jul 2016.
Health Resources and Services Administration. 340B Drug Pricing Program: eligibility & registration. http://www.hrsa.gov/opa/eligibilityandregistration/index.html. Accessed 27 Jul 2016.
Levinson D. State Medicaid policies and oversight activities related to 340B-purchased drugs. Department of Health and Human Services, Office of Inspector General; 2011 Jun. http://www.hrsa.gov/opa/programrequirements/reports/medicaidpoliciesandoversities062011.pdf. Accessed 15 Jul 2016.
Report to the congress: overview of the 340B Drug Pricing Program. MedPAC; 2015 May. http://www.medpac.gov/docs/default-source/reports/may-2015-report-to-the-congress-overview-of-the-340b-drug-pricing-program.pdf?sfvrsn=0?. Accessed 29 Jul 2016.
Wachino V. RE: implementation of the covered outpatient drug final regulation provisions regarding reimbursement for covered outpatient drugs in the Medicaid program [letter]. Department of Health and Human Services; 2016 Feb 11. https://www.medicaid.gov/federal-policy-guidance/downloads/smd16001.pdf. Accessed 18 Oct 2016.
Myers and Stauffer LC. Alabama pharmacy: FAQs. http://www.mslc.com/Alabama/PharmacyFAQs.aspx. Accessed 27 Jul 2016.
Medicaid.gov. Affordable Care Act federal upper limit methodology and data elements guide. 2016. https://www.medicaid.gov/medicaid-chip-program-information/by-topics/prescription-drugs/true-up/xxxxxdraft-true-up-methodology.pdf. Accessed 27 Jul 2016.
Mullen P. The arrival of average sale price. Biotechnol Healthc. 2007;4(3):48–53.
Giled S, Haninger K. Medicare Part B reimbursement of prescription drugs. ASPE Issue Brief. US Department of Health and Human Services; 2014 Jun 1. https://aspe.hhs.gov/report/medicare-part-b-reimbursement-prescription-drugs. Accessed 24 Sep 2016.
Medicare Part B drug average sales price: manufacturer reporting of average sales price (ASP) data. Center for Medicare & Medicaid Services; 2016. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/index.html?redirect=/mcrpartbdrugavgsalesprice/10_vaccinespricing.asp. Accessed 27 Jul 2016.
MAC pricing incents more affordable Rx. Express Scripts; 2016. http://lab.express-scripts.com/lab/insights/drug-options/mac-pricing-incents-more-affordable-rx. Accessed 27 Jul 2016.
Social Security Office. Use of the average sales price methodology. 42 U.S.C. § 1395w-3a(c). https://www.ssa.gov/OP_Home/ssact/title18/1847A.htm. Accessed 29 Sep 2016.
Medicaid.gov. Medicaid Drug Rebate Program. 2016. https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Prescription-Drugs/Medicaid-Drug-Rebate-Program.html. Accessed 27 Jul 2016.
Pharmacy Benefit Management Institute (PBMI). 2016 trends in specialty drug benefits report. 2016 Mar. https://www.pbmi.com/shop/specialty-drug-benefit-reports/2016-specialty-drug-benefit-report/. Accessed 29 Sep 2016.
Connole P. Pay-for-value movement turns attention to prescription drugs. Atlantic Information Services; 2015. https://aishealth.com/archive/nhpw071315-04. Accessed 15 Jun 2016.
Tonks A. Merck offers money back guarantee on finasteride. BMJ. 1994;309:1252–3. doi:10.1136/bmj.309.6964.1252a.
Deloitte. Value-based pricing for pharmaceuticals: implications of the shift from volume to value. 2015. http://www.converge-health.com/sites/default/files/uploads/resources/white-papers/valuebasedpricingpharma_060412.pdf. Accessed 27 Jul 2016.
Matthius A. Novartis strikes pay-for-performance deals for heart-failure drug Entresto. PM360; 2016 Feb. https://www.pm360online.com/novartis-strikes-pay-for-performance-deals-for-heart-failure-drug-entresto/. Accessed 27 Jul 2016.
The Henry J. Kaiser Family Foundation. Summary of the Affordable Care Act. 2013. http://kff.org/health-reform/fact-sheet/summary-of-the-affordable-care-act/. Accessed 27 Aug 2016.
Center for Medicare & Medicaid Services. About the CMS Innovation Center. 2016. https://innovation.cms.gov/About/index.html. Accessed 27 Jul 2016.
The Maryland Health Services Cost Review Commission. Maryland All-Payer Model agreement. 2014. http://www.hscrc.state.md.us/documents/md-maphs/stkh/MD-All-Payer-Model-Agreement-(executed).pdf. Accessed 27 Jul 2016.
Centers for Medicare and Medicaid Services. Medicare Part B Drugs Payment Model. 2016. https://innovation.cms.gov/initiatives/part-b-drugs. Accessed 18 Oct 2016.
MedPAC. Ch. 3: Part B drug payment policy issues. Report to the Congress: Medicare and the health care delivery system. 2015. http://www.medpac.gov/documents/reports/chapter-3-part-b-drug-payment-policy-issues-(june-2015-report).pdf?sfvrsn=0. Accessed 27 Jul 2016.
CMS.gov. At risk: pre-existing conditions could affect 1 in 2 Americans: 129 million people could be denied affordable coverage without health reform. The Center for Consumer Information & Insurance Oversight. https://www.cms.gov/CCIIO/Resources/Forms-Reports-and-Other-Resources/preexisting.html. Accessed 3 Oct 2016.
Obamacare Facts. Obamacare facts: an independent site for ACA advice. http://obamacarefacts.com. Accessed 27 Jul 2016.
Pearson C. Avalere analysis: exchange benefit designs increasingly place all medications for some conditions on specialty drug tier. Avalere Health An Innovation Company. http://avalere.com/expertise/life-sciences/insights/avalere-analysis-exchange-benefit-designs-increasingly-place-all-medication. Accessed 27 Jul 2016.
Goldman D, Joyce G, Zheng Y. Prescription drug cost sharing: associations with medication and medical utilization and spending and health. JAMA. 2007;298(1):61–9.
Ollove M. States limiting patient costs for high-priced drugs. The Pew Charitable Trusts; 2015 Jul 2. http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2015/07/02/states-limiting-patient-costs-for-high-priced-drugs. Accessed 18 Oct 2016.
Reinke T. Benefit and formulary options appear in specialty pharmacy. Managed Care; 2014. http://www.managedcaremag.com/archives/2014/1/benefit-and-formulary-options-appear-specialty-pharmacy. Accessed 4 Sep 2016.
ASHP Expert Panel on Drug Product Shortages, Fox ER, Birt A, James KB, Kokko H, Salverson S, et al. ASHP guidelines on managing drug product shortages in hospitals and health systems. Am J Health Syst Pharm. 2009;66:1399–406.
Fox E. National drug shortages. University of Utah Drug Information Services; The American Society of Health-System Pharmacists; 2016. http://www.ashp.org/menu/DrugShortages. Accessed 27 Jul 2016.
PhRMA. Drug shortages and supply chain info. http://www.phrma.org/drug-shortages. Accessed 27 Jul 2016.
Pollack A. Drug goes from $13.50 a tablet to $750, overnight. New York Times. 2015 Sep 20. http://www.nytimes.com/2015/09/21/business/a-huge-overnight-increase-in-a-drugs-price-raises-protests.html?_r=0. Accessed 27 Jul 2016.
Pollack A. Big price increase for tuberculosis drug is rescinded. New York Times. 2015 Sep 21. http://www.nytimes.com/2015/09/22/business/big-price-increase-for-tb-drug-is-rescinded.html. Accessed 18 Oct 2016.
Dyer O. Company reneges on promise to cut price of toxoplasmosis drug. BMJ. 2015;351:h6472. doi:10.1136/bmj.h6472.
Garrison LP, Mansley EC, Abbott TA 3rd, Brenaghan BW, Hay JW, Smeeding J. Good research practices for measuring drug costs in cost-effectiveness analyses: a societal perspective: the ISPOR Drug Cost Task Force report-part II. Value Health. 2010;13:8–13.
Hay JW, Seeding J, Carroll NV, Drummond M, Garrison LP, Mansley EC, et al. Good research practices for measuring drug costs in cost effectiveness analyses: issues and recommendations: the ISPOR Drug Cost Task Force report-part I. Value Health. 2010;13:3–7.
Mansley EC, Carroll NV, Chen KS, Shah ND, Piech CT, Hay JW, et al. Good research practices for measuring drug costs in cost-effectiveness analyses: a managed care perspective: the ISPOR Drug Cost Task Force report-part III. Value Health. 2010;13:14–7.
Mullins CD, Seal B, Seoane-Vazquez E, Sankaranarayanan J, Asche CV, Jayadevappa R, et al. Good research practices for measuring drug costs in cost-effectiveness analyses: Medicare, Medicaid and other US Government payers perspectives: the ISPOR Drug Cost Task Force report-part IV. Value Health. 2010;13:18–24.
Mycka JM, Dellamano R, Kolassa EM, Wonder M, Ghosh S, Hay JW, et al. Good research practices for measuring drug costs in cost effectiveness analyses: an industry perspective: the ISPOR Drug Cost Task Force report-part V. Value Health. 2010;13:25–7.
Acknowledgements
The authors would like to acknowledge Dr. Eberechukwu Onukwugha for providing significant commentary to drafts of the manuscript. The authors would also like to acknowledge members of the Drug Cost Focus Group (DCFG).
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JM served as the moderator for the Drug Cost Focus Group (DCFG), contributed significant input to the Results, Discussion, and Conclusion sections, and led the literature review. RV contributed significant input to the Introduction and Results sections and responded to comments. SB contributed significant input to the Results and Discussion sections and assisted in responses to reviewers. EM contributed significant input to the Methods section and provided commentary for revisions of the manuscript. SV contributed significant input to the Methods section and provided commentary for revisions of the manuscript. LP co-moderated the DCFG, provided significant input to the research design and assessment of literature, and provided commentary for revisions of the manuscript.
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This work was unfunded.
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Jacquelyn McRae has no conflicts of interest. Randy Vogenberg is on a speaker’s bureau for employer-sponsored health plans on healthcare trends and benefit plan strategy or design topics. Silky Beaty has no conflicts of interest. Elizabeth Mearns has no conflicts of interest. Stefan Varga has no conflicts of interest. Laura Pizzi has no conflicts of interest. The authors and members of the DCFG represent a diverse work group and experience in health economics and healthcare policy in the US market.
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McRae, J., Vogenberg, F.R., Beaty, S.W. et al. A Review of US Drug Costs Relevant to Medicare, Medicaid, and Commercial Insurers Post-Affordable Care Act Enactment, 2010–2016. PharmacoEconomics 35, 215–223 (2017). https://doi.org/10.1007/s40273-016-0458-0
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DOI: https://doi.org/10.1007/s40273-016-0458-0