Coming Soon: A Masterclass on Using Utilization Management on Obesity Meds

I promise I’ll deliver this at a more reasonable hour tomorrow.

The instant reaction to yesterday’s blockbuster study that showed that the Wegovy weight-loss drug also has an impact on cardiovascular outcomes seems to be “Good news! Insurance will cover this now!”

It was literally a Bloomberg headline (“Insurers Can’t Avoid Covering Weight-Loss Drugs Forever”), and the idea got traction from the Wall Street Journal and STAT, among others. I don’t want to pick on Bloomberg, because Lisa Jarvis is a great journalist and way smarter than I am, but -- respectfully -- insurers are going to work like heck to limit the use of these meds, outcomes data or no outcomes data.

Yes, the medicines are more likely to be “covered,” but insurance coverage isn’t a binary. There are lots of ways to “cover” meds but make access as hard as possible.

My expectation is that we’ll see all manner of hurdles put in the way of prescribing. There will be monster prior auths. Super-creative step therapy requirements. All kinds of requirements around comorbidities. Formulary placement that hits patients in the pocketbook. We’re going to see a masterclass in utilization management.

I wish it didn’t have to be that way. It’s going to exacerbate inequity. Rich people will pay out of pocket. Rich employers will use low-hassle coverage of weight-loss drugs as a recruitment tool.

As I harped on yesterday, the reality is we’re going to be spending a lot on these medicines — insurers aren’t crying wolf … this really is going to do a number of budgets — and we’re almost certainly not going to have a national debate about tradeoffs that are required.

(Well, we might have kind of a national debate. Congress is probably going to have to intervene to get Medicare to cover. More on that soon, I’d imagine. Like, probably, tomorrow.)

Yesterday, I joked that AHIP needed to “pick a lane”: there is a lot of cognitive dissonance involved in bragging that PBMs are keeping drug costs down while -- in the same breath -- claiming that drug prices are going up.

Today, it’s the advocates over at Protect Our Care that are trying to spin something, anything, into a claim that drug prices are going up, evidence be damned. They have a “GREED WATCH” series (all-caps in the original) release that castigates Lilly for having great quarterly earnings.

“While they make billions, Americans pay exorbitantly high prices for prescription drugs,” the release exclaimed.

Except … over the first half of this year, the prices of Lilly medicines have gone down. And that’s not a new phenomenon. Prices at Lilly went down last year. And the year before that.

So how is it that Lilly is generating boffo numbers, even as prices fall? More Americans are using its medicines. In theory, that’s excellent news: more access, lower prices. But that story doesn’t fit well with an ALL CAPS narrative about skyrocketing drug prices, so instead we get invective.

Not constructive.

• Big congrats to Dan Leonard, who was named executive director at We Work for Health.

• The folks at Janssen are doing a really good job of creating a foundation of evidence to demonstrate how destructive copay accumulators and maximizers are. (Accumulators and maximizers are ways of ensuring that patient assistance is diverted to payers rather than patients.) The latest is a paper in the Journal of Managed Care and Specialty Pharmacy -- and an infographic from Janssen -- that looked at accumulator program use and determined that the burdens on patients fell hardest on minority and underserved communities. Not cool.

• This is a massively unfair op-ed about 340B, but it’s a good summary of all of the explicitly anti-pharma talking points. At least, it’s mostly unfair … the bits about math are not entirely misguided, but they’re still a red herring. 340B is an issue regardless of whether the program is ginormous or merely huge. It’s from John Hassell of the AIDS Healthcare Foundation, and I’d argue that those Hassell represents are probably being hurt far worse by abuses by large hospitals than they are by pharma.

• It’s a pretty good time to be a big, successful nonprofit hospital, but that might not be true for long. The latest move against nonprofits comes from a bipartisan group of name-brand Senators, who are asking the IRS and the Treasury Department to look into whether nonprofits are really contributing the kind of charity care they should.

• Headline of the day: “Drug middlemen say Ohio law raises prices. Then they admit they don’t know.”