Spotlight on Market Access

Payers and manufacturers continue to exhibit broad interest in executing value-based pharmaceutical pricing agreements. But multiple factors — some of them amplified by the coronavirus pandemic — could pose challenges for those agreements as the health care industry tries to shake off effects of the pandemic and get back to more normal business, industry stakeholders say.

As drug prices remain on an upward trajectory, many copayment assistance programs offered by pharmaceutical companies have helped patients — particularly those on costly specialty medications — stay adherent to their treatment regimens. But many payers have pushed back against these programs, contending that the offerings undermine their benefit designs. Copay accumulator and maximizer programs operated by payers are the latest attempt to circumvent the manufacturer assistance, and they are growing in popularity. Manufacturers should be tracking them to see how their therapies, as well as their patient-assistance programs, are impacted by these tactics.

Centene Corp. celebrated the end of 2020 by closing on its acquisition of specialty pharmacy PANTHERx Rare, LLC on Dec. 30, then started 2021 with an agreement to acquire Magellan Health, Inc. The deals will strengthen Centene’s expertise in the specialty pharmacy space, particularly in the burgeoning orphan drug arena, by bringing onboard PANTHERx, an experienced company that’s shown remarkable growth over the past 10 years.

In addition to creating “one of the nation’s largest behavioral health platforms,” Centene Corp. will add another pharmacy-related asset to its portfolio with its recently announced $2.2 billion proposed purchase of Magellan Health, Inc.

In the year ahead, Trump administration drug pricing policies are likely to be changed or revoked by the Biden administration and court challenges, although which policies will be affected — and to what extent — is still unclear, policy experts tell AIS Health.

Centene Corp. on Jan. 5 said it agreed to acquire Magellan Health, one of the largest independently held providers of behavioral health services in the U.S. Magellan is currently contracted to serve 19 payer clients (see the top three below), which enroll about 16.5 million medical lives overall, according to the latest update to AIS’s Directory of Health Plans. Centene owns the fifth-largest behavioral health organization (BHO) in the national payer landscape, Cenpatico, and is also affiliated with Managed Health Network, a BHO inherited from Centene’s 2016 acquisition of Health Net. Centene is also set to acquire Magellan’s wholly owned PBM, Magellan Rx Management. Magellan currently serves 5.5 million pharmacy lives, while Centene’s PBM subsidiary Envolve Pharmacy Solutions has 6.1 million lives as of MMIT’s third-quarter 2020 lives data update.

People being treated for advanced prostate cancer now have a new oral option, offering patients the ability to not have to visit a provider for administration — an especially welcome alternative during the COVID-19 pandemic. And a recent Zitter Insights survey indicates that the majority of oncologist respondents likely will prescribe it, with many saying they expect to favor it over the current standard of care.

With COVID-19 continuing to ravage the United States and vaccinations still in the early stages of rolling out, the pandemic seems likely to remain the dominant headline in 2021. But other potential occurrences could have big impacts. AIS Health spoke with a variety of industry experts about what they’re keeping their eyes on in 2021.

As the Supreme Court decides on the fate of the Affordable Care Act (ACA), much of the focus understandably has been on the millions of people who would lose health insurance coverage and protections for pre-existing conditions if the law is overturned. Another not-so-often-discussed ramification of such a ruling is that the biosimilars market could be completely upended. While industry experts tell AIS Health that such an outcome probably will not occur, they still recommend that stakeholders prepare for this possibility.

Per-member per-year (PMPY) specialty drug spending rose 13.6% from 2018 to 2019, according to Pharmaceutical Strategies Group’s annual report, which analyzed 45 million pharmacy claims and 54 million medical claims. Contributing to the growth was a 10.3% increase in utilization and a 3.3% rise in costs per claim. Specialty drug spending under the pharmacy benefit saw the largest increase, driven by 19.6% higher utilization of such therapies. In terms of overall cost, inflammatory disorders ranked No. 1 among all drug categories, followed by oncology and multiple sclerosis.