PBM formulary changes, 340B growth, rising healthcare costs, and more.

September 17, 2024

Welcome to NPC This Week! We hope you'll join us each week for a look-ahead at the policy, research, and industry conversations that matter to the future of biopharmaceutical innovation. The DMs are open if you have suggestions — and please share with your network. - Michael Pratt and Devon Bortz

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NPC Highlights

PBM Formularies Announce Changes: Several PBMs have announced moves in recent weeks to increase biosimilar uptake. Biosimilars Review & Report discussed the shifts and highlighted NPC’s survey on self-funded employers and negotiated rebate guarantees.

Value Viewpoint: In her latest “Value Viewpoint,” NPC Chief Strategy Officer Kimberly Westrich discusses a new JCER editorial on the market design for innovative pharmaceuticals and reviews an updated calendar of ICER’s upcoming reports & meetings.

Industry News

Cancer Medicines & Part D OOP Caps: Research published in JAMA Network Open models the impact of the new Medicare Part D cap on out-of-pocket prescription drug spending, projecting that enrollees with cancer could see a median of >$7,000 in savings for oral cancer medications.

PBM Market Consolidation: The American Medical Association used commercial and Part D data to investigate market consolidation among PBMs, finding that the four largest entities in the U.S. control 70% of the national PBM market.

• More: A study published in JAMA asserts that large PBMs strategically monopolize specific payer segments to cement market share in U.S. retail and managed care pharmacies. PBM market concentration could impact medication access and health disparities for patients, argues study author Dr. Dima Mazen Qato of the USC Schaeffer Center for Health Policy & Economics .

340B Growth Post-ACA: A new IQVIA white paper investigates how changes stemming from the Affordable Care Act led to a “misalignment between 340B revenue and the size of the vulnerable population” as more people gained health insurance.

ICYMI

Rising Healthcare Costs for U.S. Employers: According to a new Reuters survey, U.S. employers anticipate a 5.8% rise in health insurance costs in 2025 due to increased medical service expenses, higher usage, and factors such as worker shortages, behavioral health spending, and growing use of GLP-1 weight loss medications.

• Go Deeper: NPC’s President and CEO John O’Brien breaks down the share of overall U.S. health spending in this analysis shared on LinkedIn.

What’s a SoLV, Anyway?: An article in PharmaVoice highlighted a new analysis from Milliman focusing on a new drug valuation method called the "standard of living valuation" (SoLV).? The method would incorporate real-world evidence “that accounts not only for the clinical benefit of a treatment, but other parts of a patient’s life that contribute to health outcomes.”

• Value Viewpoint: In her September 6 edition of the “Value Viewpoint ,” NPC Chief Strategy Officer Kimberly Westrich summarizes the features and differentiators of the SoLV model compared to the quality adjusted life year (QALY) and other valuation approaches.

Access for Cancer Patients: Reporting by Tom Murphy of The Associated Press highlights preliminary research on anti-nausea tablet access by University of Pennsylvania oncologists. The study found that more than half the plans sold on the U.S. individual insurance marketplace limit the number of anti-nausea tablets that patients can get, with doctors worrying restrictions will harm patient care.

Pennsylvania vs. PBMs: An audit of Pennsylvania Medicaid revealed an overspend of $7 million in 2022 for prescription drug benefits, citing ineffective oversight and lack of transparency from pharmacy benefit managers (PBMs) as the two main causes.

340B Deviation: Tom Schatz of the Council for Citizens Against Government Waste argued that the 340B drug pricing program has deviated from its original purpose and that the lack of accountability in the program has allowed hospitals to profit without benefiting patients, undermining the healthcare safety net for millions.

Mark Your Calendar

September 30: On the first day of the 2024 Fierce Biotech Summit in Boston, NPC President and CEO John O’Brien will join Christie Bloomquist, Vice President of Government Affairs and Policy at Astellas Pharma, Andrew Kaplan, Senior Vice President of U.S. Public Affairs at Takeda, and Joy Russell, Vice President of External Affairs at Genentech, for a panel discussion on “Political Pathways: Navigating the 2024 Election Cycle in Biotech.” The session aims to empower biotech industry leaders with actionable insights and strategic approaches to thrive amidst the complexities of the 2024 election cycles and its implications on the industry landscape. Learn more and register to attend the 2024 Fierce Biotech Summit here.

October 14-17: The NPC team is heading to Las Vegas for AMCP Nexus 2024! On October 15, NPC Chief Strategy Officer Kimberly Westrich will participate in a panel on “What You Need to Know About Copay Accumulators, Maximizers, and Alternative Funding Programs.” The session will take place from 8:30 – 9:45 AM PT and will include a deep dive into the regulation and potential employer implementation of accumulators, maximizers, and AFPs. More to come on NPC’s conference presence. Register for AMCP Nexus 2024 here.

October 16-18: The 14th Annual Association for Value-Based Cancer Care (AVBCC) Summit and Educational Program will take place in New York City (and virtually) this year from October 16-18, and NPC President and CEO John O’Brien is taking part in three panel discussions! Dr. O’Brien’s talks will focus on both the current status and the potential impact of the 2024 election on cancer care providers, patients, and the biotech industry at large. Learn more and register to attend the AVBCC Summit here.

November 7: At the Galien Forum, NPC President and CEO John O’Brien will join a panel discussion on “BioPharma Pressure Points: PBMs, Pricing, Access, and the Global Supply Chain.” Joining Dr. O’Brien for the conversation: Ariel Katz, Co-Founder and CEO of H1, Daniel Mendelson, CEO of Morgan Health, JPMorgan Chase & Co., Janet Woodcock, Former Principal Deputy Commissioner of the U.S. FDA, and Ezekiel Emanuel, Vice Provost for Global Initiatives at the University of Pennsylvania. Learn more and register to attend the Galien Forum here.

November 18-20: Will you be at the National Alliance Annual Forum in Arlington, VA? If so, be sure to connect with the NPC team! First up, on November 18 from 2:15 – 3:45 PM, NPC Chief Strategy Officer Kimberly Westrich will be leading a PBM Misalignment Initiative workshop. The next day, November 19, from 11:30 AM – 12:25 PM, NPC President and CEO John O’Brien will join a panel discussion on “Unlocking Value: Building Trusted Tools to Assess High-Value Care.” Dr. O’Brien will speak alongside Sarah Emond, EVP & COO of ICER, Shawn Gremminger, President and CEO of the National Alliance of Healthcare Purchaser Coalitions, and Caroline Peterson, Executive Director of the Peterson Center on Healthcare. Learn more and register to attend the National Alliance Annual Forum here.