Making Drugs Affordable. There is Disagreement About The Recipe | AHIP 2024

The session was titled “Making Prescription Drugs Affordable and Accessible for Everyone.” That is a tall order, and three panelists at the keynote session at the AHIP annual meeting last week in Las Vegas had different ideas about how it might be met.

The lively discussion among Merith Basey, M.Sc., Vin Gupta, M.D., M.St., M.P.A., and Adam Kautzner, Pharm.D., did feature some areas of overlap. There was, for example, some shared finger pointing at pharmaceutical companies for setting high list prices and a shared opinion about the importance of biosimilars to bringing down the price of biologics.

Merith Basey, M.Sc.

But there were also some tense, but restrained, exchanges between Basey, who is executive director of Patients for Affordable Drugs, a patient group that emphasizes its independence from pharmaceutical and other drug industry-related funding, and Kautzner, who is president of Express Scripts, one of the three largest pharmacy benefit managers in the U.S., and Evernorth Care Management, both of which are parts of Cigna.

“Let's not leave out pharmacy benefit managers today,” said Basey after talking about proposed patent reforms directed at changing the practices of pharmaceutical companies. “This is part of the problem that's keeping prices high. We know this. They’re black boxes. And we would like to see more transparency in this regard as well.”

“I know that a lot of folks will say we are here to benefit patients, which is the purpose and I understand that,” Basey added. “But I think it's time to show the public the receipts. And this is why the FTC [Federal Trade Commission] is investigating what goes on behind that curtain.”

The FTC launched an investigation of the pharmacy benefit management (PBM) industry two years ago, and its chair, Lina Khan, has suggested that the inquiry has dragged because companies are not complying with the commission’s requests for information

Adam Kautzner, Pharm.D.

Kautzner responded to Basey’s pointed remarks by repeating some an assertion that he began the session with: That Express Scripts’ negotiations with drug companies and pharmacies had saved its clients $38 billion last year.

“We're going to continue to do good work on behalf of our clients each and every day to negotiate with drug manufacturers to bring that [prescription drug] cost down, to negotiate with pharmacies to bring that cost down, and to ensure that patients have affordable access to medications each and every day,” said Kautzner, adding that he was going to comment on any pending litigation.

Basey and Kautzner also had a somewhat edgy back-and-forth earlier in the session when Kautzner said that “clinically, the right patients are going to have to be identified” to help rein in the cost of expensive gene therapies. When Basey asked him what he meant by “right patients,” Kautzner said patients who will benefit most from those products, to which Basey asked, rhetorically, “so only a subsection of patients” will access to these drugs.

“I'm saying,” responded Kautzner, “that based on the criteria, and the multibillion dollar cost of these products, we do need to perform due diligence to ensure that patients that can benefit the most receive those products.”

Vin Gupta, M.D., M.St., M.P.A.

Otherwise, Basey, Kautzner and Gupta, chief medical officer for Amazon Pharmacy, were largely agreeable as they covered mainly familiar territory in the seemingly endless discussion about how to best rein in U.S. drug costs. Lauren Aronson, a partner at Mehlman Consulting, a Washington, D.C., lobbying firm, and executive director of The Campaign for Sustainable Rx Pricing (CSRxP), moderate the session. 

Gupta, not surprisingly given hisposition at Amazon Pharmacy, trumpeted mail-order pharmacy as a proven way to improve adherence and refill rates. Gupta expressed concern about efficacy of the new Alzheimer’s drug and the possibility of people taking expensive drugs with little if any clinical benefit. “With all of our payer friends out there in this audience — those that are actually having to wrestle with the economics of this — to me, we have to go back and say what do people want and are we having the discussions on goals of care early enough, so that we're prepared for these types of conversations?” When topic of the glucagon-like peptide 1 (GLP-1) drugs was introduced by Aronson, Gupta spoke about the value of “deprescribing” — eliminating unneeded prescriptions — after mentioning some research that suggests that some people who took a GLP-1 for weight loss can stop taking the medication and still keep the weight off.

Notwithstanding her mention of PBMS, Basey directed most of her criticism at the pharmaceutical system and held out hope that bills introduced in Congress would become law and change patent and other laws to bring about more competition, by among other things, limiting “patent thickets,” multiple patents on a drug,

“Competition is a critical lever to lower drug prices in this country, and around the world, across the board,” Basey said. We know that when a generic enters the market, it is likely to be able to reduce, on average, the price of a drug by 20%. If you have six competitors, you can reduce the price of the drug by about 95%. So this is why we need competition. But let's be clear the current system and the patent system is being abused by the pharmaceutical industry. It's rigged in their favor against patients to keep prices really high. It's not a free market.”

Gupta, a pulmonologist, joined Basey in assailing patent practices, noting that patents on the drugs to treat chronic obstructive pulmonary disorder were not on the active ingredients but on the inhalers. The same is true of Ozempic (semaglutide), one of the GLP-1s, he said: “Twenty-one of the 25 patents on Ozempic are not on the active ingredient. They are on the injection device. It is absurd,” said Gupta.

Kautzner spoke about Express Script’s has developed a “solution” to high gene therapy costs that involves a plan that has “simple per member per month fee, and we cover the drug.” The company does its “own clinical due diligence” on the drugs. He said the company is also working to make manufacturers more accountable with value-based “solutions” that will involve following patients for many years.

Kautzner sounded an optimistic note about biosimilars gaining a firm foothold in the market. The savings from biosimilars, he said, “is going to help pay for many of these other really expensive therapies that we're now talking about.” Kautzner mentioned that Evernorth is selling its own biosimilar to Humira (adalimumab). In April 2024, Evernorth announced that it was selling a Humira biosimilar through Accredo, its specialty pharmacy, with a list price that is 85% lower than Humira’s list price.

Kautzner mentioned patient skepticism about biosimilars, and Gupta also discussed patient skepticism that biosimilars and generics were a “less than” alternative to brand-name drugs.

“We need more of these biosimilars. We need more generics, because what the people that we hear from every day are saying is not that they're refusing an option. They're just saying we can't afford the option that we are being offered,” said Basey.