Discussions
Drug Manufacturers’ Suits Against Medicare Price Negotiations Ring Hollow
With the announcement of the first drugs subject to the IRA in 2026, the drug industry filed lawsuits to prevent CMS from implementing the program. Their only true motivation is to forestall loss of revenue on lucrative products, not preventing future innovation.
The Value of Denying Valid Medical Claims
I’ve written about aspects of the patient journey in the past, and one thorny difficulty is the problem of inappropriate claim denials. Note, I used the word “difficulty” here, not “challenge” because there is no need for diplomacy here. When someone is seriously ill...
The Drug Industry Rightly Fears Judicial Overreach
I am appalled that this subject needs to be addressed. The US Food and Drug Administration (FDA) isn’t perfect, but it is still the global gold standard for evaluating medicines for safety and effectiveness. The FDA, though not quite recovered from the self-inflicted...
From Wellness Apps to Prescription Digital Therapeutics
Throughout its development, the US healthcare system has been attracted to new and shiny technologies like bees to honey. This is a significant reason why the cost of healthcare rises over time. It is also one reason why value-based care initiatives show smaller...
Federal Trade Commission to Investigate PBM Practices
Scrutiny on pharmacy benefit managers (PBMs) has just been ratcheted up considerably. The Federal Trade Commission (FTC) announced on June 7 the launch of its investigation into PBM practices, targeting the largest players. This investigation comes at an extremely...
FDA Taking a Big Gamble on Alzheimer’s Drug; Expect Payers to be Wary [at Best]
It is difficult to speculate on what FDA’s motivation might be to overrule the recommendation of its Advisory Committee and approve Biogen’s aducanumab for the treatment of mild Alzheimer’s disease. Relatively few providers are convinced of the value of this agent...
Does Meeting an Unmet Need Justify a Premium Drug Price?
The pharmaceutical industry sometimes forgets how payers calculate the value of their products. Payers do not view value solely through the lenses of clinical efficacy, safety, and utility. The case for the value of a COVID-19 vaccine to prevent disease or an...
A Simple Plan: Universal Catastrophic Care
In our previous post, we documented the difficulties and challenges in considering a “Medicare-for-all” scenario to extend coverage to virtually everyone. We also discussed the potential for implementation of a “public option,” which was first proposed with the...
If Medicare for All Won’t Work, What Possibly Can?
Some election-year topics are hotter than others, and now that impeachment seems to be behind us, many expect that the topic of health care access will heat up. Not that this hasn’t gained plenty of press and airtime in the past few months. The Democratic presidential...
If Mandatory Bundled Payments Save Little, What Will?
It is well known that the cost for specific procedures in US hospitals is not only far higher than in most Western countries, but it may be far greater from hospital to hospital in the same geographic area. And this may not include an apples-to-apples comparison of...
How Can Health Plans and PBMs Escape the “Rebate Trap”?
The rebates given to pharmacy benefit managers to secure a drug’s place on the formulary have become a difficult barrier to coverage for new products. The rebate income for these PBMs is sometimes passed on to health plans, insurers, and employer purchasers, but more...
How Economic Value Became a Big Part of a P&T Committee’s Considerations Today
Years ago, the undeclared rule of law was that a Pharmacy and Therapeutics (P&T) Committee’s deliberations must be free of cost concerns. This rule is increasingly being overturned. The P&T Committee, as a formulary decision-making body, was supposed to decide...
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