Obamacare: Questions for Pharma in 2014

Tom Norton outlines the Obamacare-related questions that are likely to be of concern to pharma companies in the U.S. this year.

It’s expected that about 35 new FDA approved prescription drugs will arrive on the market in 2014. What are the chances that these new medications will be utilized by Obamacare health programs?  Given that the majority of these products are likely to be high cost, specialty drugs, dedicated to small, niche markets, pharma execs should anticipate that the chances of these drugs becoming first line Obamacare prescription options are going to be relatively low.

However, as several of these anticipated prescription drugs will address unmet needs in areas such as rheumatoid arthritis, cystic fibrosis, and various blood cancers, it’s possible that they may be included in various higher end Obamacare insurance offerings.

But, it’s also very likely that the only way to access these new products will be with prior authorization approvals, and very substantial copays.

Emphasis on “preventive medicine” Rx products
Will the heightened emphasis on “preventive” medicine in Obamacare result in greater physician utilization of prescription drugs designed for the treatment of chronic conditions? And given the need for compliance, how well will the new Obamacare patients stick to their prescribed Rx regimes, including refilling those preventive medicine prescriptions when needed?

Pharm execs will need to watch the development of the various “preventive medicine” trends to ascertain how those Rx products are actually being utilized in the evolving Obamacare health insurance climate.

But probably the biggest general preventive care question of all is “will the new Obamacare emphasis on preventive care actually lower healthcare costs?”

Rx copay “shock”
Another huge economic factor next year is the prospect that many of the new patients who sign up for the “bronze” and “silver” Obamacare health plans are going to end up paying very substantial copays in 2014 to obtain their prescription drugs. What impact will this have on the Obamacare patients?

Although the Rx industry has managed copay challenges in the past, the anticipated extremity of these Obamacare prescription copays may shock a lot of the new program’s patients. Clearly, the prepared pharma exec will have to find ways to mitigate the Rx copay surprises in 2014, and beyond.

Thinking about this, what can a pharma exec really do to assist patients who are denied access to their company’s medications due to high copays in a healthcare plan?  Here’s an intriguing question: Will 2014 be the year that U.S. pharma considers revamping those fading “patient assistance plans” to deal with extraordinary Obamacare copays?

Lost “high prescribing” physician access
One of the clearest strategies that the Obamacare healthcare insurance plans will utilize to will be lowering the number of physicians who will be practicing in the Obamacare networks.

In the main, this will be accomplished by utilizing more community hospitals and smaller, local health centers.  This means the services of thousands of physicians who practice in more expensive, urban specialty hospitals will in many cases be excluded from new Obamacare health offerings. This will be done as the fees charged at the larger, urban institutions charge are viewed as “too expensive” by Obamacare insurers.

Therefore, to get care, many Obamacare patients will have to “switch” to new doctors who are located outside of their home neighborhoods. They will also experience a new type of “lower cost” medicine that will be practiced by these doctors that will include a limited number of prescription drugs that are listed on highly restricted formularies.

Why is this important to the Rx industry? Because many of the brand name industry’s “high prescriber/early adopter” physicians practice in those urban, specialty hospitals. Assuming these higher cost, urban physicians are discriminated against in the Obamacare system, it will mean that the general use of newer, more expensive brand name drugs could drop, and likely drop substantially.

The net result, some argue, will be a clearly defined two-tiered system of Rx care in the U.S. That is, many of the people who buy Obamacare health plans will have access to fewer, cheaper drugs and not be able to access the services of “high prescribing” doctors who use innovator drugs, while those Americans who will continue to be covered through their private employers will enjoy much more robust Rx coverage.

The new medical culture of 2014: “less is more”
So, for pharma execs across the U.S., 2014 will present the first manifestations of the broader Obamacare “medical culture” that will continue to take shape as the years go by.  Generally, what can U.S. pharma expect?  Reviewing all that we know today, and it is obviously a confused picture, it does appear that the new Obamacare Rx “ethic” will be built around the idea that, “less is more.”

In general then, as this new medical culture begins to take hold, for the 85% of Americans who are currently enjoying some level of private medical care and who had access to the latest Rx prescriptions prior to launch of Obamacare, 2014 will likely begin to feel like they are getting “less” prescription drug care than they had in the past. However, for those 15% of Americans who for the first time will be getting access to many older, lower cost Rx products, it will definitely feel like “more” prescription care is being provided - a lot more.

For the U.S. pharma exec, then, there’s more than a little bit to think about this year.  My guess is that on several levels, 2014 is likely to be the beginning of an entirely new “medical culture” that the U.S. Rx industry will have to quickly learn how to manage in the years to come. There really is no other option.

Tom Norton is Principal at NHD Smart Communications.