Spotlight on Market Access

Extending inflation-based prescription drug rebates to all commercial health plans, rather than just applying them to the Medicare program, could potentially save as much as $8.1 billion annually, a recent Health Affairs study finds.

The Inflation Reduction Act (IRA) requires pharmaceutical manufacturers to pay rebates to Medicare if they raise prices faster than the rate of inflation for certain drugs. To gauge the effects of extending the program beyond Medicare, researchers analyzed 130 million claims — comprising 16,107 drugs — for 11 million enrollees in commercial plans in 2021. They found that if the IRA rebate program was applied to the entire commercially insured population, savings would be largely driven by a small number of drugs with high total spending.

When the Medicare Drug Price Negotiation Program became law a few years ago, supporters cheered that CMS would finally be able to negotiate prices on drugs for Medicare beneficiaries. But manufacturers criticized it, calling it government overreach that would threaten drug development. To link into that, researchers at the IQVIA Institute for Human Data Science analyzed initial drug approvals and expansions that followed and found that due to some aspects of the program, clinical development after a drug’s initial approval may indeed be impacted, according to a new report, titled Proliferation of Innovation Over Time: Frequency, Timing and Clinical Value of Expansions Post-Initial Approval.

Genentech USA, Inc., a member of the Roche Group, provided funding for the report.

The SCAN Group, a not-for-profit health care organization founded in 1977 as the Senior Care Action Network, is the parent company of SCAN Health Plan, one of the largest Medicare Advantage (MA) insurers in its home state of California. SCAN offers health insurance products for older adults and Medicare-Medicaid dual eligibles, including MA and Special Needs Plans (SNPs), serving markets in California, Arizona, Texas and Nevada. In recent years, SCAN has begun offering tailored MA plans that cater to the unique health care needs of diverse communities, including women, LGBTQ+ seniors and Asian Americans. The company nixed merger plans with fellow nonprofit insurer CareOregon in early 2024.

While the “Big Three” PBMs’ private-label subsidiaries have drawn recent attention for their agreements with pharma companies to offer their own branded biosimilars, one of these planned arrangements has landed a manufacturer in hot water.

Johnson & Johnson and its Janssen Biotech, Inc. subsidiary — now known as Johnson & Johnson Innovative Medicine — on Feb. 24 filed a lawsuit (Case 2:25-cv-01439) against Samsung Bioepis Co. Ltd. over its attempts to sell a private-label biosimilar of J&J’s interleukin-12/IL-23 antagonist Stelara (ustekinumab) via an unidentified PBM private-label subsidiary in addition to Samsung’s Pyzchiva (ustekinumab-ttwe) biosimilar.

Private equity firms continued to invest in health care at a steady pace in 2024, despite the increasing regulatory scrutiny and high interest rates, according to an annual report from the Private Equity Stakeholder Project.

The report tracked 1,049 unique PE-backed health care deals in 2024, a 7.6% decrease compared to 2023. The deals included 166 leveraged buyouts, 262 growth/expansion investments, and 621 add-on acquisitions to 383 unique platform companies. At least 16 PE firms completed 10 or more deals. And at least 13 PE-owned platform companies made five or more add-on acquisitions, over half of which were dental care companies.