The Votes Have Been Tallied: Curve Readers Say the Big CMS Reveal Will Come the Week of Aug. 19

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If you only read one thing today, make it this Magnolia Market Access survey looking at how payers are going to handle price controls in the IRA. 

The answers show that plans and PBMs are going to go all in on restrictive formularies and hardcore utilization management. And while that shouldn’t necessarily be surprising, it’s stark to see it laid out so clearly. 

There have been groups -- particularly those representing patients and physicians -- shouting about the possible negative impact on access to the IRA for a while now. And I suspect that as we get closer to 2026, you’re going to see a lot more commentary and concern here.

Well, this was interesting. I appreciate all of you who took the time to vote in last week’s poll about when CMS would release the prices on the IRA’s first batch of “selected drugs.” 

My assumption going in was that there would be a lot of votes for the next couple of weeks, based on the logic that it would be best -- politically -- to have those prices out in advance of the Democratic National Convention so that speakers could point to the IRA as a crowning success. 

But it turns out that a plurality of you had a slightly different take, thinking that there would be an extra boost if the prices and the DNC hit at the same time. 

Now I’m even more curious about what comes next. 

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The second most interesting poll last week was this one, from Rep. Jake Auchincloss, asking about which catalysts for PBM reform would be the most effective: legislation, litigation, or competition. 

It’s not really a fair question -- some combination of the three will come into play -- but the answers, again, are revealing. A majority went for “legislation” -- probably not a surprise given the source -- but the conversation it is spawning will be illuminating.

• The introduction of the big Senate 340B reform bill -- promised last week -- has been punted to later this year. Axios reported on the 11th-hour decision to hold the bill back, and 340B Report implied that there were all kinds of issues, including that “multiple stakeholders had issues with parts of the bill.” It sounds like consensus here will be harder to come by than may have been suggested. I’m shocked, shocked. 

• One of the great unforced health policy errors of the past decade has been the misplaced concern about the cost of hepatitis C drugs, where alarms about budget impact were used as an excuse to under-cover hugely useful, cost-effective medicines. The latest bit of amazing health economics research on hep C pills -- just published by University of Washington researchers -- found that well over a half-trillion dollars in economic gains can be linked to the drugs, and that society captured 90% of the value. The companies who actually delivered the revolution received 6.5%.

• I’ll be honest: I’m not quite sure what to make of the earnings-call comments from Cigna CEO David Cordani (Cigna owns Express Scripts), who suggested that the “friction” in the environment around PBM is due to their excellent negotiation prowess and promised to be more “aggressive” in telling its story. It’s been a bad couple of weeks for Express Scripts, and it’s interesting to see an exec position the challenges as an issue with the narrative, rather than an issue with the business practices themselves. 

• The IRA is massively driving up Part D plan spending, which -- in turn -- is massively driving up the subsidies that the federal government will provide to maintain the illusion of limited premium growth. Here’s CMS on the topic, along with an overview from KFF.

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