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Are Drug Pricing Formulas Full Employment Acts For State Attorney Generals?. Gerard Anderson PhD Professor Johns Hopkins University. Lake Wobegon Syndrome : How Can Everyone Be Getting A Better Deal?. U.S. vs. Other Countries Medicaid vs. Other Payors Maryland vs. California

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Are drug pricing formulas full employment acts for state attorney generals
Are Drug Pricing Formulas Full Employment Acts For State Attorney Generals?

Gerard Anderson PhD

Professor

Johns Hopkins University


Lake wobegon syndrome how can everyone be getting a better deal
Lake Wobegon Syndrome : How Can Everyone Be Getting A Better Deal?

  • U.S. vs. Other Countries

  • Medicaid vs. Other Payors

  • Maryland vs. California

  • Maryland Medicaid vs. Maryland Prisons


Economics 101 fixed vs variable costs
Economics 101 – Fixed vs. Variable Costs Deal?

  • Fixed Costs

    • costs that must be incurred regardless of number of units sold

  • Variable Costs

    • costs of producing one additional unit

  • Examples

    • Fixed - plant and equipment or R & D

    • Variable - materials



Variable costs first decrease and then increase
Variable Costs First Decrease Deal? and Then Increase


Standard Economic Theory – Price Determined By Where Variable Cost is Lowest - Fixed Costs are Irrelevant

Firms Produce Where Variable Cost is Lowest


In reality fixed costs matter
In Reality –Fixed Costs Matter Variable Cost is Lowest - Fixed Costs are Irrelevant

Pharmaceutical companies could not exist if everyone only paid only the variable cost


Most pharmaceutical spending involves fixed costs
Most Pharmaceutical Spending Involves Fixed Costs Variable Cost is Lowest - Fixed Costs are Irrelevant

  • Marketing: 32.8%

  • Costs of Goods Sold: 25.3%

  • Profit: 20.6%

  • R & D: 14%

  • Taxes: 7.3%


64 000 policy question
$64,000 Policy Question Variable Cost is Lowest - Fixed Costs are Irrelevant

  • Who should pay the fixed costs of pharmaceutical companies?

    • U.S. vs. other counties

    • Medicaid vs. other payors

    • Maryland vs. California

    • Maryland Medicaid vs. Maryland Prisons


Who is paying the fixed costs
Who Is Paying The Fixed Costs? Variable Cost is Lowest - Fixed Costs are Irrelevant

  • U.S. pays twice as much as other countries

  • Almost 2 to 1 difference in government payors:

    • Medicare

    • 340 B

    • Medicaid

    • VA

    • DoD

  • Some states pay 3 times what other states pay

  • Significant variation within state programs


Policy issue spillover effects
Policy Issue – Spillover Effects Variable Cost is Lowest - Fixed Costs are Irrelevant

  • If payor (e.g. Medicaid) gets a lower price then will other payors have to make up the difference?

    • One economic assumption:

      • Pharmaceutical companies will be able to raise prices to other payors (programs) to cover their fixed costs

    • Alternative economic assumption:

      • Each payor (program) negotiates the best price independently of what other payors (programs) pay


My perspective on spillover effects
My Perspective On Spillover Effects Variable Cost is Lowest - Fixed Costs are Irrelevant

  • Each pharmaceutical executive will want to maximize the revenue from each payor (program)

  • Result is that states need an economic not just a legal rationale for getting low drug prices


Full employment for attorney generals
Full Employment for Attorney Generals Variable Cost is Lowest - Fixed Costs are Irrelevant

  • Without an economic rationale companies will try to maximize revenue in Medicaid by “gaming” the system


Unlike most goods and services the consumer is not king in pharmaceutical pricing
Unlike Most Goods and Services the Consumer Is Not King In Pharmaceutical Pricing

  • Physicians must prescribe drugs

  • Hospitals, nursing homes, HHAs use formularies

  • Pharmacies can push drugs that earn them greater profits

  • Patients pay small portion of bill out-of-pocket



Remember the spread
Remember the Spread Pharmaceutical Pricing

  • Spread is the difference between pharmacy (hospital, LTC, HHA) purchase price and what Medicaid believes is the purchase price

  • In 2002 CBO calculated that pharmacies earned the following spreads in Medicaid

    • 23% overall

    • 30% generics

    • 14% brand names


What are the economic incentives
What Are The Economic Incentives? Pharmaceutical Pricing

  • Drug companies want pharmacies to earn the most money on their drugs so they will prescribe them

  • Pharmacies will want to prescribe drugs that earn them the most money

  • Both drug companies and pharmacies benefit when the spread is greater

  • Medicaid loses when the spread is larger


Trust me i am from pharma
Trust Me I Am From Pharma Pharmaceutical Pricing

  • The source of all the pricing data is the pharmaceutical companies

    • AWP, AMP, ASP, EAC, FUL, MAC, WAC


Amp and best price
AMP and Best Price Pharmaceutical Pricing

  • Average Manufacturers Price (AMP) is supposedly what a drug company receives for a drug in a given quarter from retail pharmacies

  • Best price is supposedly the lowest price in retail pharmacies

  • Medicaid rebates are determined based on difference

  • How can any state validate either best or AMP?


Auditing
Auditing Pharmaceutical Pricing

  • CMS investigated pharmaceutical company reported data on only 4 occasions over a 10 year period according to GAO


Lake wobegon
Lake Wobegon Pharmaceutical Pricing

  • Rebates are difficult to monitor when the pharmaceutical industry has all the data

  • Not every state can be getting the best deal

    • Some states pay almost 5 times more for the same drug


Price transparency
Price Transparency Pharmaceutical Pricing

  • Find out the actual prices other payors are paying for the same drugs

    • U.S. vs. Other Countries

    • Medicaid vs. Other Payors

    • Maryland vs. California

    • Maryland Medicaid vs. Maryland Prisons


Comparative data allows a bully pulpit
Comparative Data Allows A Bully Pulpit Pharmaceutical Pricing

  • With comparative price data states can see where they are getting a good deal and when they are paying higher prices

    • Must be done on a drug by drug basis

  • States can then focus their negotiations on the prices of drugs where they pay much higher prices


Conclusion
Conclusion Pharmaceutical Pricing

  • Who is going to pay the fixed costs of the pharmaceutical industry?

  • Gaming will occur without an economic rationale for discounts and rebates

  • Cannot rely on pharmaceutical companies for all the data to determine prices

  • Price transparency will tell states when they are getting a good deal


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