Krishna Patel, PharmD

Payers (including CMS!) have reservations about paying for Obesity treatment today. L.E.K. Consulting looked at claims data and found that total cost of care for chronically obese patients is ~14% lower for persistent GLP-1 users compared to GLP-1 naive patients. These findings should help support insurance coverage, medicine access, and reimbursement for the patients who need it the most. Read more here: https://lnkd.in/eHq4PGh2

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Hot off the press! CMS has recently released a video that talks about The Medicare Prescription Payment Plan and how seniors can select smoothing. This has been a concern for many pharma programs - here is the link below to share with all your colleagues to share with patients. #CMS #Medicareprescriptionpaymentplan #Medicare #Smoothing

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It feels like negotiated prices in Medicare should be favored over high cost, high rebate but the math doesn't work out. There is a terrific article in the Pink Sheet on how Medicare-negotiated prices may not get favorable coverage but I'll just be more blunt -- plans are good at negotiating and will likely stick to what works for them. I thought a breakdown with some visuals might make it come alive for those who don’t live in this every day. Background: The Inflation Reduction Act has Medicare setting the price of ten drugs starting in 2026. For first year, the drugs chosen are in competitive classes that would require them to give back significant rebates to payers to have formulary access. But Medicare is going to “negotiate” prices based on either a Maximum Fair Price calculation (% off based on time on market) OR a weighted average of the Part D rebated price or some other magical calculation which we don’t know yet. Example: $600 drug that is being “negotiated” starting in 2026. In 2026, the Medicare price for the drug is reduced to $240. A win for Medicare and patients! The beneficiary is now responsible for $60 (25% of the $240) and the plan is responsible for $156 (65% of $240). Manufacturers who are “negotiated” do not owe the 10%/20% liability for the drugs in the program, the government pays that liability to plans. The liability to the plan overall is $36. The manufacturer has provided $390 worth of value in the negotiated price. A competitor that is not negotiated, would face a similar story to the 2025 drug but now looks better than the negotiated competitor because it is a lower price AND providing cash to the plan as part of the rebate. And cash is better than not having cash. PLUS, plans get to keep a % of the amount over the plan bid which means those rebates become profit. (If you want to learn more MedPAC payment basics or Milliman.) My understanding of the math is that plans will keep less of each rebate dollar in 2026 compared to 2024 BUT it is still more valuable than a lower price. So we're stuck in a high price, high rebate cycle. It is possible that the “negotiated” drug will come up with another $30 to make its liability similar to the year before and to give it an advantage to its competitors but maybe not. It does partially depend on what plans are required to do by CMS. But you can see that negotiated prices aren’t awesome for plans...there is talk of them including the negotiated product on formulary but with utilization management (prior authorization, step therapy) or at a higher tier.

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It's rare nowadays to discuss pharmacy pricing without mentioning #NADAC. It's interesting to think back to when it was mostly a niche topic within Medicaid, and even then, it didn't get much attention. But with the push for more transparency in drug pricing, NADAC has become a hot topic. This is an interesting read for those looking to understand what NADAC is and how it's derived; and for those following it more closely, some insight as to what happened to NADAC pricing in April. #PharmacyBenefits #DrugPricing #Transparency

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A great day for patient access in ESRD! CMS Policy Update announced Monday November 25, 2024. Beginning in January 2025, CMMI’s Kidney Care Choices (KCC) value-based care model will carve out Transitional Drug Add-on Payment Adjustments (TDAPA payments) from financial calculations such as benchmarks, performance year expenditures and USPCC trend rates, allowing ESRD patients participating in a KCC to have increased access to certain innovative new drugs https://lnkd.in/gpFQ2RS6

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And we're off - IRA's impacts to the drug industry and pricing. One table offers substantial insights into "maximum fair price" and how many patients will be effected by each Brand. https://lnkd.in/gvwDMy9X

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Multiple major new/revised PBS listings this month. Alas, none of these health care technologies was listed under 500 days of TGA approval. #marketaccess #timelines #reimbursement #pbs #dataanalytics #datascience #hta #medtech #innovation

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Trying to catch up on Medicare Part D changes and what to make of them? I present you the latest Medicare Access for Patients Rx (MAPRx) white paper on the unintended consequences of the Inflation Reduction Act changes in Medicare Part D. https://lnkd.in/efzwkFJ5

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Thoughts on this? >> Exclusive: Walmart shut down its healthcare clinics after losses reached nearly a quarter of a billion dollars >> Comment below! >>> lqventures.com #strategy #competitiveintelligence #marketing #biotech #productmarketing #pharmaceutical #pharma #healthcare

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From 2016 to 2023, Epic increased its acute care hospital market share from 26% to 39%; meanwhile, Oracle’s share held flat at about 25% until decreasing to 23% in 2023. Additionally, Epic controls 52% of the acute hospital care market by bed count, more than double that of Oracle. Thus far, Oracle and other, smaller competitors have been unable to curb Epic’s rise, as Epic was the only EHR vendor to increase its hospital-bed market share last year.

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How to blow $230 million/year: - Sell a big market forecast with Standard Model thinking - Confuse said big market forecast (i.e., metrics) for a strategy - Point resources and capabilities in the wrong direction - Change said wrong direction early and as often as possible - Assume expert knowledge of the past is the way to construct a future - Ignore, misread or pretend-away the 'ground truth' from the frontline And when the mathematical gymnastics packaged in the PowerPoint don't manifest NOW in terms of the 'next $1 billion in growth' or, even better, delivering on the true center of the American Way of Healthcare (i.e., more shareholder value), throw in the towel, announce layoffs and revert to the place you're comfortable with conceptually. Says Walmart in a statement to Endpoints News: "What we learned through Walmart Health centers will help us continue to innovate and support the healthcare needs of our communities through our legacy pharmacy and vision." Possible, but not probable. By definition, the only place a "legacy" vision can lead is back to the past. If there's a "learning" here -- the kind of thing Harvard Business School can package in a PowerPoint to sell as a new corporate/executive education program -- is that making big market innovation come to life is hard work. It isn't a solo sport (Walmart can/would have fared better collaborating with a big pharmaceutical company on the roadmap). And it doesn't start with a forecast that everyone knows is bullshit, particularly the people buying and selling it. The upside of a new market is unknowable at the start, just ask the team at Amazon/Amazon Web Services (AWS), who ten years ago invented what is now a $600 billion market for 'cloud infrastructure' services. They had no idea it could be that large. But maybe the biggest learning of all is that making a Big Dent happen, particularly in healthcare, takes time, a more original vision and a completely different starting point. Quoting from the epigraph to War and Peace: "The two most powerful warriors are patience and time." via Shelby Livingston

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I'll leave the legal issues to you - what I cannot ascertain is has anyone commented on, if the IRA plan expands as people have said it will, then how will new drug discovery be funded? It's an incredibly time consuming and expensive process. To expect companies to do this for free isn't reasonable. Once the trials are in humans, the investigators and institutions need to be funded. In some cases the administrative costs are high as well: patient travel, patient hospitalization and other family domiciling, new machinery, staff to administer trial drug, monitor patients, etc. Then of course there is the ROW benefits of the American system paying for drug. Innovation year over year is what is saving lives. I'm not sure how the whole process works if we stunt it on a larger scale.

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Thoughts on this? >> Industry groups critique new guidance for Medicare drug price negotiations in 2027 >> Comment below! >>> lqventures.com #strategy #competitiveintelligence #marketing #pharma #biotech #productmarketing #healthcare #pharmaceutical

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