Radar on Drug Benefits

Amid a summertime resurgence of ire directed at major PBMs, CVS Health Corp., The Cigna Group and UnitedHealth Group during their recent earnings calls each took the opportunity to defend their pharmacy benefits businesses and tout their new, more transparent offerings. 

When reporting CVS’s second-quarter financial results on Aug. 7, CEO Karen Lynch opened her prepared remarks with the bad news first, revealing that the continued struggles of the firm’s health benefits division led her to cut its 2024 earnings forecast and fire Aetna President Brian Kane. But she then sang the praises of CVS Caremark — as well as hit back at major PBMs’ critics. 

With the Medicare Part D national average monthly bid amount (NAMBA) set to spike 180% next year, CMS late last month unveiled a new demonstration program aimed at stabilizing a market that is experiencing unprecedented volatility. 

However, some Republicans in Congress are up in arms over the demonstration, arguing that it contains “extra-statutory, eleventh-hour policy changes” aimed at cleaning up a problem created by the Biden administration’s most-touted health policy achievement.  

Commercial and government payers can play a key role in generating real-world evidence (RWE) and helping the health care system reduce costs and improve outcomes, according to a special communication published last month in JAMA. Meanwhile, speakers at a July 25 virtual meeting sponsored by Duke University’s Margolis Institute for Health Policy emphasized that payers should work together with pharmaceutical companies, medical device manufacturers and policymakers to institute better ways to incorporate RWE into practice. 

Mark McClellan, M.D., Ph.D., director of the Margolis Institute and a former FDA commissioner and HHS administrator, defined real world data as “data relating to patient health status and/or the delivery of health care routinely collected from a variety of sources” such as registries, wearable devices and electronic health records. He added that RWE is “clinical evidence about the use, potential benefits or risks of a medical product or practice or care delivery model that’s derived from the analysis of real-world data.” 

With policymakers and industry stakeholders increasingly focused on the cost savings opportunities tied to biosimilars, a new Health Affairs study sheds light on some of the factors that influence uptake of these near-copies of pricey biologic medications.

Among almost 200,000 commercial and Medicare Advantage enrollees who newly initiated one of seven biologic drugs with available biosimilar versions — filgrastim, bevacizumab, epoetin alfa, trastuzumab, pegfilgrastim, infliximab and rituximab — the share of people initiating a biosimilar increased from 1% in 2013 to 34% in 2022. Patients who were younger than 18 years were less likely to initiate a biosimilar than other age groups. Meanwhile, enrollees in commercial high-deductible health plans were more likely to use a biosimilar, compared with those in MA plans.