December 7, 2021

Can the badly broken prescription drug market be fixed?

High drug prices are a key reason health care is unaffordable for millions of people. With the right policy solutions, we can get back on the path to affordability.

By Anthony A. Barrueta, Senior Vice President, Government Relations

In a free market sellers compete on price and buyers choose the goods with the lowest price that meet their needs. It’s a fundamental law of economics that is immutable — at least in the pristine world of economics textbooks. In the real world the law often crumbles; and nowhere has it crumbled more than in America’s prescription drug market.

It doesn’t take an economist to recognize that drug manufacturers rarely compete on price. This is one reason why, even during a global pandemic, the prices for prescription drugs continued to outpace inflation 2-to-1. And it’s a key reason why this country spent $535.3 billion on prescription drugs last year. It wasn’t always this way. There was a time when health plans and other buyers had some power to negotiate with drug manufacturers to keep prices in check.

Government policy and higher drug prices

In the early 1990s, a series of public policy changes systematically undermined any leverage buyers had to help rein in rising costs. One such change was the Medicaid Drug Rebate Program created by Congress in 1990. Under the program, any manufacturer that wants its drug covered under Medicaid must agree to pay a rebate to the state Medicaid program to essentially create a lower drug cost.

Policymakers created the Medicaid Drug Rebate Program in response to rising drug prices and to help Medicaid receive discounts comparable to what other payers in the market obtain. However, the way the program calculates rebates — requiring that Medicaid receive the “best price” in the market — prevents manufacturers from offering deeper discounts to private purchasers. This, in turn limits potential cost savings for the majority of Americans who rely on private health insurance for their coverage. Instead, manufacturers are only willing to sell drugs to private purchasers at a price they have agreed to sell it to the Medicaid program. In effect, the drug industry is protected by a structural price support.

At the same time the Medicaid Drug Rebate Program was undermining private health plans’ ability to negotiate discounts, those plans began paying for an increasingly larger share of prescription drugs.

Coverage expansion for drugs, even before Medicare started offering outpatient prescription drug coverage for beneficiaries in 2006, means most consumers have become largely insulated from the full price of drugs. While this has protected many consumers and allowed them to afford their medications, patients who are unaware of the full price of a drug face less pressure to choose a lower-priced pharmaceutical (though some health plans come with considerable deductibles and high copays).

Overall, this combination of policies — which discourage real discounts, expand coverage, and insulate consumers from the actual prices of drugs — has allowed manufacturers to raise prices relentlessly with both political and market impunity.

Policy solutions do exist

Today, the broken prescription drug market contributes heavily to making health care unaffordable for millions of people. But all is not lost. New approaches, such as allowing Medicare to negotiate some prices where competition is limited or nonexistent, are being considered by Congress, and the following policy options should be considered as well:

  • Address anticompetitive behavior and drug patent abuse. Drug companies have pricing power because the federal government grants them patents that stave off competition. When a drug is covered by a patent, only the pharmaceutical company that holds the patent is allowed to make and sell the drug for a period of time.

    While patents are important to stimulate scientific advancement and innovation, many drug companies have abused that protection, even when the underlying research was heavily financed by the public. For example, the original patent on AbbVie’s Humira expired in 2016, but more than 100 other patents protect it through 2034.

    There are ways we can build a fairer patent system. We can start by requiring greater transparency about how drugs were actually developed and challenging "patent thickets," complex webs of patents that make it harder to bring generics and biosimilars to market.

  • Improve the use of biosimilars, as we do at Kaiser Permanente. Biosimilar drugs are less expensive, highly similar alternatives to pricier biologic drugs, and work just as well. For instance, Neulasta, a drug to fight infections for people undergoing chemotherapy, costs more than $10,000 per milliliter, while a biosimilar called Ziextenzo is almost 40% less expensive and delivers comparable results.

  • Focus more on the evidence of a drug’s safety and efficacy. We pay far too much for many drugs that have shown to minimally improve health outcomes or show little value over alternative treatments. For example, a recent report found that drug companies increased costs in our health care system an additional $1.7 billion in 2020 by raising prices on just 7 drugs, even though there was no evidence of clinical improvement for patients.

  • Curb the effects of direct marketing to consumers. One survey found that 1 in 8 adults were prescribed a specific drug after seeing it in an advertisement and asking their doctor about it. Consumers and providers need more unbiased sources of information about pharmaceuticals to help counter potentially misleading marketing efforts. We need transparency in marketing tactics so we truly understand how these practices may be inappropriately influencing prescribing and increasing drug spending.

    PharmedOut, a project of Georgetown University Medical Center, recently shared some fresh thinking about pharmaceutical marketing tactics, their impact, and where we should go from here.

  • Limit marketing directly to doctors. At Kaiser Permanente, pharmacists work hand in hand with doctors and other clinicians to adhere to an evidence-based drug formulary. We significantly restrict marketing by pharmaceutical sales representatives, which could deter doctors from prescribing equally effective generics or high-value therapeutic alternatives.

The prescription drug market is broken. Patients, care teams, and payers suffer from a tangled web of policies that undermine competition and divorce price from value. But it is not too late.

Looking beyond what may be accomplished in any particular Congress or legislative session, it’s time for our lawmakers to have some serious conversations about the solutions listed above. Patients deserve access to drugs proven to work at prices we all can afford.