Jump to content
The World News Media

Arthritis Medicine Is New Front in War on Costly Drugs


Recommended Posts

  • Member



Dr. Glen Stettin, the chief innovation officer at Express Scripts. The company is advising insurers and employers to cover a narrower range of anti-inflammatory drugs to try to foster competition and control prices. Credit Dilip Vishwanat for The New York Times

Americans have expressed outrage at drug companies for raising prices on products like EpiPen, the severe allergy treatment needed by thousands of children, and Daraprim, a rarely used but essential drug to treat a parasitic infection.

But insurers and employers — who pay the bulk of the cost for drugs — say that a bigger financial shock has come from a largely overlooked source: expensive anti-inflammatory medications like Humira and Enbrel, drugs taken by millions of people for conditions like rheumatoid arthritis. In recent years, the price of the medications have doubled, making them the costliest drug class in the country by some calculations.

Now, one of the most powerful forces on the side of drug payers is pushing back. On Thursday, Express Scripts, the nation’s largest drug benefits manager, changed its recommendations to insurers and employers, saying they should cover fewer drugs for many inflammatory conditions. The idea is that the new limits will force drug companies to lower their prices, saving insurers and employers money.

The approach has already set off some complaints among patients, who rely on regular injections of the drugs to keep painful and uncomfortable symptoms in check. If an approved drug does not work, patients will have to take extra steps get a different drug. But Express Scripts said that the move was necessary to contain costs. The drugs account for nearly 10 percent of all drug spending among its members in the United States, the company says — costing an estimated $7.5 billion — even though fewer than 1 percent of its members use them.

“This is a category of drugs that are used for crippling, very painful conditions, yet they don’t affect huge numbers of people,” said Dr. Glen Stettin, the chief innovation officer at Express Scripts. The rising costs, he said, are due less to a rising number of patients who need the products and “much more because of the increase in the prices of these medications.”

The approach is the latest effort by insurers and drug-benefit managers to more closely manage drugs in high-cost diseases, limiting which ones are covered or requiring patients to take additional steps to get approval for certain products. In 2014, Express Scripts shook up the market for hepatitis C drugs when it required its patients to use a new treatment by AbbVie rather than more expensive competitors. It made similar moves last year with the approval of expensive new treatments for high cholesterol.

Like those previous efforts, the effort for inflammatory conditions will most likely help the company’s mail-order specialty pharmacy, Accredo. Express Scripts said patients getting the anti-inflammatory medications through the new program would need to use Accredo, not a competing pharmacy, giving the service a bigger base of customers.

Continue reading the main story

As a drug benefit manager, Express Scripts provides services like negotiating with drug companies and approving or denying drug claims. The new program is voluntary for employers and insurers who use the company, but its recommendations are usually widely adopted.

Humira, made by AbbVie, and Enbrel, made by Amgen, each carry a monthly list price of just over $4,000, and each have increased those prices by about 130 percent from 2011 to 2016, according to the Gold Standard Drug Database compiled by Elsevier Clinical Solutions. That price does not include rebates that the manufacturers negotiate with insurers. Express Scripts said that the actual monthly cost of anti-inflammatory drugs, before the new program, was about $3,000.

Representatives for large employers, who subsidize the health insurance of their employees, said the efforts were welcome. Drugs like Humira and Enbrel are known as specialty drugs, a category of products that treat serious conditions and whose rising costs have increasingly alarmed those who are paying the bills.

“If you go back to 2014, it wasn’t even on the radar screen for employers, and now it’s No. 1,” said Brian J. Marcotte, the chief executive of the National Business Group on Health, which advocates for large employers.

But some patients questioned whether it would further limit the options for some people or make it more cumbersome to get the medications they needed. The program would apply only to new patients; those already stable on drugs would be allowed to remain on them.

“Jumping through hoops may not seem like a big thing to somebody that doesn’t have to live with the condition,” said Nicole Martin, 33, of Blaine, Ky., who has rheumatoid arthritis and takes Enbrel. “But even being a day or two behind can cause massive issues for somebody.”

Traditionally, patients were offered all the drugs that were covered by their plans no matter which inflammatory condition they had — from rheumatoid arthritis to psoriasis and ulcerative colitis. Under the new guidelines, Express Scripts has devised a separate list of preferred and nonpreferred drugs for each condition. Patients who want to use a drug on the nonpreferred list will need a letter from their doctor.

The company said the move would require drug companies to compete more directly. The motivation to get on the preapproved list, the company said, would push drug companies to offer better discounts to employers and insurers. Express Scripts declined to provide specifics about the discounts that it had negotiated through the new program.

“We expect to make a big dent in the cost of caring for people in this category, without compromising the care that people get,” Dr. Stettin said.

Dr. Stettin said the company looked at patient data first when deciding which drugs would be preferred. “Clinical always comes first, and the cost is second,” he said.

Representatives for drug companies, including AbbVie and Amgen, said they believed doctors and patients — and not insurance companies — should decide which therapy is best. And they said the list price does not reflect the rebates and other discounts that insurance companies and drug-benefit managers negotiate, which make the actual cost lower.

“Because of the magnitude of these rebates,” said Kristen Davis, a spokeswoman for Amgen, “price increases have become part of the competitive dynamic.”

The program will also refund up to $2,000 a month to employers and insurers if a patient has to switch from a preferred drug to a different medication in the first three months, a potential savings of about $250 million a year. About a quarter to a third of patients end up switching to a new drug in the first few months, Express Scripts said.

But that money-back guarantee does not necessarily go to the patient, even if the patient has a high-deductible plan and paid for all or most of the drug. Employers will decide whether to pass that refund along to the patients, Express Scripts said.

A reason that the rising cost of drugs like Humira and Enbrel hasn’t stoked greater outrage is that many patients are shielded from the costs. In addition to the discounts the companies negotiate with drug-benefit managers, AbbVie and Amgen run assistance programs that often reduce patients’ out-of-pocket costs. The average Express Scripts member paid $127 in monthly co-payments for a drug to treat an inflammatory condition, the company said.

Dr. Stettin said patients would be better served by using the company’s specialty pharmacy, Accredo, which has pharmacists that specialize in inflammatory conditions. He cited company data showing that patients with those conditions were more likely to take their drugs when they used Accredo compared with other pharmacies.

But some industry observers said the move was a ploy to build Accredo’s mail-order business, by essentially locking in patients whose employers opt in to the new program, then making money by filling the prescription.

“They really, really want their hands on that script,” said Michael Rea, the chief executive of Rx Savings Solutions, which advises employers on how to reduce drug costs.

Link to comment
Share on other sites

  • Views 359
  • Replies 0
  • Created
  • Last Reply

Top Posters In This Topic

Popular Days

Top Posters In This Topic

Popular Days

Join the conversation

You can post now and register later. If you have an account, sign in now to post with your account.
Note: Your post will require moderator approval before it will be visible.

Reply to this topic...

×   Pasted as rich text.   Paste as plain text instead

  Only 75 emoji are allowed.

×   Your link has been automatically embedded.   Display as a link instead

×   Your previous content has been restored.   Clear editor

×   You cannot paste images directly. Upload or insert images from URL.


  • Recently Browsing

    • No registered users viewing this page.
  • Popular Contributors

  • Topics

  • Posts

    • John-Henry takes a few minutes to explain why Yuval Noah Harari, a professor who works with the World Economic Forum, uses the terms "useless people" and "useless class" in public discourse so frequently.
    • On January 12, 2022, the United States submitted a number of amendments to the IHR that will give away even more of our sovereignty and greatly empower the World Health Organization (WHO) to restrict YOUR health related rights and freedoms. The 75th meeting of the World Health Assembly will be held in Geneva, Switzerland this May 22-28, 2022. The Assembly will vote on the amendments to the IHR. They are very likely to pass and be enacted into International law unless “We the People” stand up against this attack on our sovereignty.
    • I expect most people here don't know, but back in March, the 9th circuit reversed Wit v UBH for, basically, no reason. All the law blogs were croggled: the decision of the court was both very short and just made no sense. What's Wit vs UBH? A really important decision about a law suit against a health insurance company under a federal law called ERISA. ERISA is a consumer protection law that says if a company takes your money to provide you a financial service, they can't take advantage of the fact they have your money hostage to fleece you. It asserts the company has what's called a "fiduciary duty" – they have to behave in a trustworthy manner and do what they said they were going to do when you contract with them for a service. The Wit vs UBH suit argued that they had caught UBH, a health insurance company, making up standards of medical necessity for when they should have to pay for medical care that were in violation of widely agreed upon standards of care in medicine, and in some cases were hard or impossible for any patient to meet. All to get out of having to pay for health care services their members needed, leading to a bunch of people dying – it was a class action suit and some of the members of it were surviving family of the patients. The Wit case was particularly egregious because they found smoking-gun internal emails of doctors in the insurance company, UBH, saying to management, this is against medical standards, and we could probably be sued into oblivion if caught. There was no question what the plaintiffs alleged was actually going on, and everyone doing it knew it was criminal. The ninth circuit ruled, nah, it's cool. Insurance companies don't need to actually, you know, pay for the healthcare they charged you premiums to cover, if they can invent an excuse. Any excuse really. As a consequence, they just basically invalidated the whole of ERISA. Which doesn't just cover insurance – it covers all banking and investment companies too. Or did. And by extension, they may have just knocked over consumer protection laws as a class. Because what is anyone going to do about it? Appeal to the Supreme Court? The Supreme Court we have would love to destroy the principle of consumer protection laws.
  • Members

    • Pudgy

      Pudgy 509

      Last active:
  • Recent Status Updates

    • Mic Drop

      This Bitcoin and Crypto stuff is really starting to take off like wildfire
      · 0 replies
    • Arauna  »  Thinking

      Hi, it seems we are the only two left talking about it as the rest have lost interest.  PITY, because they will soon see what is coming. I have always had a good imagination for understanding injustice. ..I watched the video about the injustice you put up.... very sad. We understand those things.....the other video is just a parody, of snippets of a very nasty person.... I do not know who she is but she was standing  next to the health minister.....
      I am not well, so I may not make it thru this system..... and I am happy to say maybe it is a  good thing.... I want to praise jehovah until I die ...but the opportunities are getting less.... and who wants to see people suffer?  If I were still around I would be severely stressed by it.  
      My father always said " know all, blow all" when people think they know it all.  And I have seen some pretty opinionated people on here. Mostly people who have had very little suffering and had authority in congregations.   
      I encourage you to stay strong dear sister and please devote more time to worship Jehovah in love. I also want to cut my time on internet ........ I spend time trying to find hidden  news about new developments in UN etc.  Soon all news about what is really  going on will not be available..... just mandates from governments and propaganda from the governments. People will be liquidated and we will not be able to get news about it. 
      Just stay strong. I am glad you spoke out about Australia.... I have a friend there who is too afraid to talk on internet.  They have already built  Covid "camps" in USA and Australia.... the  ĺorcing all "faith in god" out of everyone..  only worship of the state will be allowed. .... to compromise as many as he can.
      Strengthen yourself. No one can do it for you. 
      · 0 replies
    • Toni  »  T.B. (Twyla)

      Thank you so much for the spiritual food!!!
      · 0 replies
    • Arauna  »  TrueTomHarley

      Hi Tom, where are u?  I miss ya! 
      · 2 replies
    • Eric Ouellet

      ג Guimel
      Ô. Jéhovah trace le chemin de ma vie;
      car en vous je met ma confiance entière.
      Vos paroles se révèlent à mon oreille.
      Je voudrais être prêt à vous servir toute au long de ma vie.
      La source de mes secrets, vous est révelé devant vous;
      votre justice est comme la lumière du soleil en plein midi.
      Seul mon Dieu peut discerner les actions de mon Âme;
      les secrets de mes pensées et de celles de mes actions.
      Ô mon Dieu Jéhovah , je voudrais recevoir l'honneur 
      de la protection du Dieu de mon Salut. 
      J'aimerais recevoir l'eau de ta source pour m'abreuver 
      comme un chameau avant le grand pèlerinage de ma foi.
      Devant vos yeux se dessine la quête de ma victoire;
      Car Jéhovah est grand et infiniment digne de louanges.
      La grandeur de votre sagesse et de votre intelligence est inscrutable.
      Je voudrais rendre grâce à Jéhovah et m'unir à tous les justes et humbles de la terre.
      Tous ensemble exaltons le Nom glorieux de notre Dieu d'amour.
      Les œuvres de notre Dieu Jéhovah sont grandioses, à tout jamais.
      Ô. Jéhovah voulez-vous protèger votre serviteur;
      afin que je vive et que j’obéisse à vos paroles?
      Ouvre mes yeux pour que je vois clairement
      les choses merveilleuses de votre loi qui sont inscrites
      à l'intérieur des paroles de votre livre merveilleux.
      Je ne suis qu’un étranger dans le pays de la terre.
      Ô mon Dieu ne me cache d'aucune manière la beauté 
      de vos préceptes qui gardent vos serviteurs en vie.
      Bénis soit celui qui me révèle le chemin que je dois parcourir;
      le désir que manifeste mon âme qui est attaché à ma poussière.
      Je voudrais connaître le secret de préserver mon âme;
      ce cadeau inestimable du seul vrai Dieu; ce lien d'appartenance que je dois préserver au gré de ma vie comme à la prunelle de mes yeux.
      Je voudrais brûler constamment de désir pour tes jugements;
      car les jugements de mon Dieu révèle sa grandeur.
      Ô. Jéhovah réprimandes les présomptueux,
      les hypocrites qui dévient de la beauté de tes commandements.
      Éloigne de moi la dérision et le mépris de ce monde,
      car je veux obéir à tes rappels et je veux être soucieux de garder 
      mon âme de toutes violences et de toutes souillures de ce monde.
      Même si les princes de ce monde se réunissent 
      pour parler contre tes serviteurs;
      Tes serviteurs méditent sur vos prescriptions;
      unie à votre amour comme un seul, nous sommes attachés à vos rappels ;
      Tous ceux qui sont avec toi au mon Dieu sont mes conseillers.
      L'humilité et ma douceur garde mes yeux éveillés à lire votre parole, jour et nuit; car votre parole est la source de la lumière qui fera briller mon âme au jour de votre salut.
      Ô. Jéhovah fait briller ta justice et ton droit comme l’aurore du soleil en plein midi.
      Les descendants de ton salut seront puissant sur la terre.
      Gloire et honneur soit rendu à notre Dieu Jéhovah. 
      Bénis soit le Dieu unique de notre Salut

      · 1 reply
  • Forum Statistics

    • Total Topics
    • Total Posts
  • Member Statistics

    • Total Members
    • Most Online

    Newest Member
    Jonathan Knowles
  • Create New...

Important Information

Terms of Service Confirmation Terms of Use Privacy Policy Guidelines We have placed cookies on your device to help make this website better. You can adjust your cookie settings, otherwise we'll assume you're okay to continue.