That, dear reader, is a ship-load of dollars, and shows just how distorted brand-drug pricing has become. Huge increases jack up list prices and in many instances consumers' costs, while those fees flow to payers, PBMs, and other entities in the pharma distribution.
Most consumers' costs are based on the total price of the drugs they buy, not the net price after rebates etc. As a result, consumers may be paying an inflated price while their insurer gets the rebate dollars. I'd note that in some benefit plans consumers do receive a share of the rebates in the form of discounted drugs or lower up-front costs. Two big PBMs indicate they give about 90% of rebate dollars to their clients.
Who hopefully pass those dollars along to their members.
Evidently, rebate contractual terms can be opaque, confusing, and subject to misinterpretation, a rather scary possibility given the billions at stake.
I recently spoke with the CEO of a company that's deep into the rebate management process. Quantivus uses technology to help payers and pharma track all those clauses, heretofores, and whereas-es in rebate contracts to be sure the right dollars are paid for the right drugs to the right entities.
Quantivus' solution helps stakeholders standardize terms and definitions, allowing them to ensure that they are comparing apples to apples when considering rival drugs – or rival payers. It does other stuff as well, and the company is working on a related service that will tie the negotiated contract to operational systems, helping to standardize reporting of rebate financials for manufacturers and payers.
It's interesting in a couple of geeky ways; evidently these contracts are so complex and convoluted that they can be mis-interpreted or misunderstood, potentially costing the pharma company or its customer millions. Which there are plenty of.
It's also interesting in that CEO Lisa Bair and her team have figured out a software solution to a problem that seems to get more complicated and more financially important by the minute.
If I was an attorney focused on rebate contracts, I'd be just a bit concerned that I could be replaced by Bair's technology.
ABOUT THE AUTHOR
Joe Paduda, the principal of Health Strategy Associates and president of CompPharma, is a nationally recognized work comp expert and speaker with considerable expertise in medical and pharmacy management. Joe consults with managed care organizations, providers, insurers, employers, and private equity firms and conducts an annual payer survey on managing work comp pharmacy. In addition to writing the popular and controversial www.ManagedCareMatters.com, he is a founder and contributor of www.HealthWonkReview.com, a collaborative blog on healthcare policy.
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