The Daily Dose
Bill Would Limit Patient Access to Cheaper Drugs
More than 25 million Americans suffer from asthma. The condition is well-known for restricting a patient’s airway, making it difficult to breathe and often causing coughing and wheezing. In addition to putting the squeeze on a person’s lungs, asthma is also putting pressure on patients’ wallets, as the cost of inhalers has risen to about $5,000 a year.
Doctors and patients were recently elated when a popular asthma medication went generic. Fluticasone/salmeterol is the first-ever generic asthma combination inhaler. It contains the same active ingredients as Advair, but for a fraction of the price – $119 per inhaler compared to $360 per inhaler. Hearing the news, CDPHP immediately moved to add the drug to its formulary (list of covered drugs), saving an average of $3,500 per year.
But what if we weren’t allowed to offer the generic to our members?
A bill circulating in the New York state legislature would do just that by prohibiting health plans – like CDPHP – from making formulary changes in the middle of a contract year. The legislation (S.5022-C/A.2317-C) purports to protect consumers from being forced to change medications mid-stream, but would lead to several unintended consequences that are bad for consumers.
Health plans are constantly searching for ways to provide consumers with access to the most clinically- and cost-effective drugs. One of the ways we do this is by updating our formularies. CDPHP and other health plans make decisions about prescription drug coverage alongside local, practicing doctors – doctors who are not employed by the plan, but sit on our pharmacy and therapeutics (P&T) committee. When a new drug comes to market, the P&T committee meets to determine whether the drug should be added to the list. Prohibiting plans from making these changes would not only limit consumer choice, but would increase the cost of care for all.
Doctors and advocates – many of them propped up by the pharmaceutical industry – will argue that mid-year formulary changes are bad for consumers. What they’re failing to mention is the impact that mid-year price hikes have on patients.
We all remember the outrage when then-Turing CEO Martin Shkreli increased the price of Daraprim from $13.50 to $750 overnight. Then there was Lomustine, a cancer drug sold by Bristol-Myers Squib that used to go for $50 a pill. The drugmaker sold the rights to a startup called NextSource, which jacked up the cost nine times. One capsule of the life-saving treatment is now $768.
At CDPHP, we believe members should have access to safe, effective, and affordable medications. Limiting our ability to be agile and respond to market changes is not in the best interest of consumers, and potentially another big win for Big Pharma.
John D. Bennett, MD, FACC, FACP About the Author
John D. Bennett, MD, FACC, FACP, is president and CEO of Capital District Physicians’ Health Plan, Inc. (CDPHP), an award-winning, physician aligned, not-for-profit health plan based in Albany, NY. Bennett has held the position since 2008 after serving more than 10 years as chair, vice chair, and board member for CDPHP. During his tenure, CDPHP has been ranked among the top-performing health plans in New York and the nation, most recently named #1 in Customer Satisfaction in the 2023 J.D. Power Member Health Plan Study. Under his leadership, CDPHP has also become known as a model employer regionally and nationally and was recently named among the top five Best Companies to Work for in New York by the Society for Human Resource Management, as well as Forbes Best-in-State Employers 2022. Prior to joining CDPHP, Bennett served as founding member and CEO of Prime Care Physicians, PLLC. During his tenure, he co-led a team of 25 cardiologists and helped grow the practice to a 100-physician multi-specialty group. Bennett is board certified by the National Board of Medical Examiners and the American Board of Internal Medicine, with subspecialties in internal medicine and cardiology. He earned his medical degree at SUNY-Downstate Medical Center, Brooklyn, and a Bachelor of Science degree at Rensselaer Polytechnic Institute. Bennett completed an internship and residency in internal medicine and a fellowship in cardiovascular disease at Albany Medical Center. He is a Fellow of the American College of Cardiology and the American College of Physicians. Bennett is currently board chair for the Center for Economic Growth and the Capital Region Chamber, and vice chair for the Palace Theatre. Bennett also serves on the boards of the New York eHealth Collaborative (NYeC), the Alliance of Community Health Plans (ACHP), America’s Health Insurance Plans (AHIP), Rensselaer Polytechnic Institute, and Russell Sage Colleges. Bennett is a member of the New York Public Health and Health Planning Council where he helps shape decisions related to New York State's public health and health care delivery system. Well-known locally and nationally for advancing health care innovation, Bennett was recently named to Crain’s New York Business 2021 Notable in Health Care, as well as the Albany Business Review’s Power 50 list.
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