Blog Archives

Over the past few years, there has been important progress in treating certain blood cancers with chimeric antigen receptor (CAR) T cell therapy, leading to the approval of two of these novel treatments last year. But ensuring patients can access these innovative therapies remains a top concern for doctors, patient advocacy organizations and other stakeholders in the life sciences community.

Those challenges were the focus of a special panel sponsored by Celgene during the 2018 Biotechnology Innovation Organization (BIO) International Conference, which was held from June 4-7 in Boston. Richard Bagger, executive vice president of Celgene Corporate Affairs and Market Access, moderated the panel, which included experts with backgrounds as varied as medical research, economics and health policy.

“We are at the threshold of a very exciting time,” said panelist Nupoor Raje, Massachusetts General Hospital. “The progress that we are seeing is promising.”

This progress also comes with challenges and potential barriers for patients. The panelists agreed that those challenges should not prevent patients who could potentially benefit from CAR T cell therapies from having affordable access to them. Part of the discussion highlighted how a number of stakeholders will need to work together to shape the regulatory and reimbursement environment for optimal patient access.

Richard Bagger

RICHARD BAGGER, EXECUTIVE VICE PRESIDENT OF CORPORATE AFFAIRS AND MARKET ACCESS AT CELGENE, MODERATED A PANEL ON ENSURING ACCESS TO TRANSFORMATIVE CANCER THERAPIES AT THE 2018 BIO INTERNATIONAL CONFERENCE.

Ensuring Access

Operationally, the production of approved CAR T cell therapies is as complex as each treatment is highly personalized and unique to every patient.  A patient’s T cells are extracted at a treatment center, sent to a manufacturing facility where they are engineered to recognize a specific protein or antigen and attack cells, including cancer cells that have this antigen, and then sent back to be infused into the patient. The process requires an unprecedented level of collaboration between doctors, health centers and manufacturers.

One of the approved CAR T cell therapies is for pediatric patients with relapsed or refractory acute lymphoblastic leukemia. Both approved CAR T cell therapies are for adults with relapsed or refractory diffuse large B-cell lymphoma after two or more lines of therapy.  Celgene CAR T cell therapies are still investigational and are not yet approved by the Food and Drug Administration.

However, a significant blockade to patient access exists—these personalized therapies don’t fit neatly into private payer or government payment models, including Medicare, meaning delays for patients and complications for providers.

The last thing we want to do is deny a patient a therapy that could potentially benefit them.

“Waiting two to four weeks for insurance approval could be too long for many of these patients,” panelist Dr. Gwen Nichols, the Chief Medical Officer of The Leukemia & Lymphoma Society, said.

And despite the financial losses that hospitals face when Medicare and insurance reimbursement does not adequately cover the costs of CAR T cell therapy, many centers continue to try to deliver timely treatments to meet patient demand, according to panelist Beth Roberts, a health policy lawyer at the firm Hogan Lovells.

As a possible solution to expedite patient access and simplify issues for providers, panelist Henry Grabowski, Ph.D., Professor Emeritus of Economics at Duke University, suggested that private and public insurers should explore innovative payment arrangements such as payment plans, flexible pricing and value-based contracts.

Patients Are Waiting

Beyond the issue of reimbursement, the health care system is still increasing capacity to provide CAR T cell therapies to more people. For instance, because of the highly specialized expertise required, only a few community cancer centers can administer CAR T cell therapies, so patients often must travel far for treatment.

Preparing today so patients can access innovative cancer treatments such as the CAR T cell therapies must be a top priority for our health care system. “We need to manage the hype and continue to let the science lead the way,” Raje said. “The last thing we want to do is deny a patient a therapy that could potentially benefit them.”

To learn why CAR T cell therapy represents an important advance for some patients, read “CAR T Cell Research Continues to Advance.”

While Blood Cancer Awareness Month provides an opportunity to raise awareness and understanding of the various forms of blood cancer, it also serves as a reminder of the progress that has been made in treating these diseases. This progress would not have been possible without the numerous individuals who are bound together to improve the lives of people diagnosed with blood cancers.

A blood cancer diagnosis significantly alters the lives of not only patients but also their caregivers, friends and family. In 2012, more than 900,000 people worldwide were diagnosed with blood cancer. In the United States, someone is diagnosed with blood cancer approximately every three minutes.

Explore a model “Day in the Life” of various individuals through the following infographics to better understand the effect blood cancer has on their daily lives.

Blood Cancer Awareness Month
Leukemia
Multiple Myeloma
MDS
lymphoma
myelofibrosis

 

As director of Patient and Non-Personal Promotions at Celgene in Seattle, Becky Holman works to ensure information is communicated to patients as clearly as possible. She knows that the work she does could potentially make a difference in the lives of patients with blood cancers, but hearing it from the patients themselves is something altogether different.

Recently, Holman had just such an opportunity when she and her Celgene colleagues were asked to read letters written by blood cancer patients for a video to mark Blood Cancer Awareness Month. It was a powerful reminder of the special bond that everyone who works at Celgene shares with patients.

“At Celgene, we are bound together with patients in this fight to find a potential cure for blood cancers,” Holman said. “We share a common goal. They are fighting for their lives, and we are fighting alongside them. Celgene and the blood cancer community are truly bound by blood.”

 

Ripple Effect

The letter that Holman read was from a man with non-Hodgkin lymphoma (NHL) named Nick, whom she’d met earlier this year in Celgene’s Seattle office. He had recently had his 100-day treatment follow-up after treatment on a clinical trial with an investigational therapy.

Nick is a firefighter who puts his own life on the line to save others, playing an essential role in his community. He had faced heat and flames—and now cancer—with bravery.

He is also memorable because of his age; while lymphoma is most commonly diagnosed among people who are aged 65 to 74, Nick is in his early 30s. He and his wife discovered they were expecting their first child after he found out that his cancer had come back following treatment with chemotherapy.

“Knowing Nick, I could already see his face while I was reading his letter,” Holman said. “He helped me understand the ripple effect of blood cancer therapies. If we can help him, he has a chance to continue to save lives in his community through his job as a firefighter. That’s an immeasurable impact.”

Every time that we meet patients or read a letter from a patient, we deepen our commitment to the people who are fighting blood cancer alongside us.

Constant Reminders

The bonds between Celgene and the blood cancer community run deep. Patients with blood cancer, like Nick, rely on the research community and companies like Celgene to continue researching new treatment options. Meanwhile, Celgene relies on patients to take part in clinical trials of those therapies to ascertain the safety and effectiveness so we can hopefully offer them to the blood cancer community.

Celgene’s promise to the blood cancer community is to always put patients first, and the company takes steps to ensure that everyone who works there never loses sight of that promise. While it’s easy to get caught up in the strategy and operations of a large company, Celgene employees embrace the opportunity to meet and engage with people like Nick whose lives have been affected by blood cancer.

“Every time that we meet patients or read a letter from a patient, we deepen our commitment to the people who are fighting blood cancer alongside us,” Holman said. “We’re reminded why we are here, why we’re doing what we’re doing. It keeps us anchored, focused, grounded. It gives us purpose and hope.”

To learn more about the special bond shared by Celgene employees and blood cancer patients, watch the “Bound by Blood” video.

Patients with plaque psoriasis who see their doctor frequently can increase their odds of finding an effective and appropriate treatment for them, especially as there are more ways to treat psoriasis than ever before. According to an analysis of the MarketScan Medicaid database, the average time between a psoriasis patient’s initial visit to the doctor’s office and a follow-up appointment is 153 days.

To raise awareness about why it’s important for patients to work with their doctors to help manage psoriasis during this year’s Psoriasis Awareness Month (August), Mark Jackson, M.D., Clinical Professor of Medicine (Dermatology) at the University of Louisville and Forefront Dermatology, explains how often patients with psoriasis should see their doctors, how psoriasis treatments have evolved and why it’s important for patients to feel empowered to help take control of their disease.

DR. MARK JACKSON

MARK JACKSON, M.D., FROM THE UNIVERSITY OF LOUISVILLE BELIEVES PATIENTS WITH PSORIASIS SHOULD SEE THEIR DOCTORS FREQUENTLY TO HELP ENSURE THE BEST POSSIBLE OUTCOMES.

How often do you recommend your patients with psoriasis see you?

“Plaque psoriasis requires active management. It’s essential that doctors make sure that their patient’s condition is improving within four to six weeks of starting a new treatment for them. Even if their current treatment is effectively controlling their symptoms, they should still see their doctors every three to six months. Seeing their physician frequently is imperative for patients with psoriasis.

That being said, if a patient is experiencing new symptoms or treatment side effects, they should call their doctor immediately.”

Why is it important that people with psoriasis see their doctors frequently?

“Psoriasis is not just a rash; it’s an inflammatory disease. Patients with psoriasis are more likely to have other health conditions, including metabolic syndrome, diabetes, heart disease and obesity. Up to 30 percent of psoriasis patients eventually develop psoriatic arthritis as well.

During office visits, doctors check the signs and symptoms of psoriasis and its comorbidities. Dermatologists are not just skin experts; we’re physicians. We can optimize our patients’ overall health and if we can assist in controlling the inflammation from psoriasis, we might possibly be able to help reduce the risk of these other conditions as well.”

What are some symptoms that you tell your patients to look out for?

“For most patients, psoriasis symptoms can fluctuate on a seasonal basis or with life changes. Cold, dry weather and stress can both trigger a psoriasis flare, and certain medications can make some symptoms worse.

Because of the increased risk of developing psoriatic arthritis, I make sure my patients are on the lookout for any joint pain and swelling. Patients should also know and watch out for the signs and symptoms of other comorbid conditions.”

The more that people with psoriasis take charge of their overall health and treatment, the better their outcomes can be.

How can doctors encourage their patients to see them more frequently?

“Doctors should foster a partnership with their patients through regular communication. The best outcomes occur if patients and doctors are both engaged and involved in their care. The more informed a patient is, the better decisions they make and the more compliant they can be with treatment.

Some patients may get scared when they learn about the risks that come with some systemic psoriasis treatments. It’s our job as physicians to thoroughly explain to our patients the risks and benefits of all their options and address their concerns, so we can make the most appropriate choice together.”

How have psoriasis treatments evolved over the past decade?

“We’ve seen a dramatic increase in the number of available psoriasis therapies as well as the efficacy and tolerability of those treatments. Newer treatments have become much more targeted compared with many of the older systemic medications, which cast a wider net on the immune system.”

Why is it important that patients feel empowered to manage their psoriasis?

“We can’t make patients take their medicines or schedule appointments, but we need to work to make them engaged participants. We can only provide the best information and try to build their confidence with the hope of helping improve their treatment compliance.

I encourage my patients to get involved with the National Psoriasis Foundation and learn more about their disease. My patients don’t always love hearing about diet and exercise, but I try to explain to them that their therapy may be more effective if they maintain a healthy body weight. The more that people with psoriasis take charge of their overall health and treatment, the better their outcomes can be.”

To learn more about how comorbidities can affect the health and care of people with psoriasis, read “Painting a Clearer Picture of Psoriasis Comorbidities.”

ASCO 2018 will be remembered for the potential paradigm changing innovations across hematologic and solid tumor diseases, but there was a critical discussion also taking place around the tremendous value these advances are offering patients.

On Friday, June 1, Celgene presented a workshop entitled “Understanding the Value of Innovation in Oncology” that looked at what value means to different stakeholders, including patients, physicians and health economists on a series of panels throughout the day.

The first session featured Dr. Rafael Fonseca of the Mayo Clinic and Dr. Anupam Jena of Harvard Medical School who spoke about why measuring value matters in oncology during this current era of increasing costs. The doctors discussed the concept of healthcare as an investment and the inherent value that research and innovative therapies are providing for patients with cancer.

Dr. Fonseca

Dr. Jena then brought Dr. Peter Neumann of Tufts University School of Medicine, Dr. John Romley of the University of Southern California, and Dr. Jason Shafrin of the Innovation and Value Initiative to talk about how we currently measure value and why context matters in these assessments. The group also discussed new approaches to measuring value including a new open-source, consensus-based approach to measure the benefits, risks, and costs involved in assigning value.

Importantly, the patient voice was well-represented during the event as Jennifer Hinkel, a patient and Partner at McGivney Global Advisors, hosted a second panel that explored what patients believe are important aspects of innovative therapies. Dr. Michael Millenson of Health Quality Advisors, Sarah Krüg, CEO of Cancer101 and patient Stuart Cornew explored the many considerations that contribute to a therapy’s profile such as clinical benefit, survival, toxicity, novelty, and quality of life, and how those factors contribute to value.

Finally, after Dr. Fonseca grounded the group in physicians’ considerations around value, he hosted a panel including Jennifer Hinkel, Dr. Jena and Dr. Neuman that looked toward the future at how different audiences can be engaged in discussions around value and how the community can overcome challenges and limitations of current approaches.

“This event was a true opportunity to hear from some of the most important voices in any discussion about value,” said Dr. Safiya Abouzaid, host of the workshop from Celgene Corporation. “By understanding what value means for each stakeholder- how it is currently assessed and how we can reflect different perspectives in that assessment- we can ensure a continuation of the kind of innovation that has improved the lives of many patients over recent years.”

Dr. Jena
 

By Mark J. Alles, Celgene Chairman and Chief Executive Officer

A few decades ago, drug discovery was, for the most part, a matter of trial and error. The world’s most successful pharmaceutical companies would often collect dirt from far-flung locales and screen that soil or sand for medically active components. Biology was often a secondary concern. It was the speed of trial and error that was important.

Today, drug discovery is more targeted and intentional, building on a wealth of data that has grown exponentially since the early days of trial and error. Our knowledge of cell biology and genomics is now sufficiently advanced that it is possible to create medicines based on our individual immune cells or genetic profile. These advances promise patient-tailored medicines, such as the new CAR T therapies that “train” the patient’s own immune system to fight cancer, that have the potential to transform how cancer is treated.

This kind of innovation, however, requires investment to be sustained. Both the basic science and the delivery of treatments require investment to foster the next generation of therapies. The challenge is ensuring access to and reimbursement for those new medicines, thereby enabling innovators to reinvest in research and development. This is the virtuous cycle of innovation.

Mark Alles

Mark J. ALLES, CELGENE CHAIRMAN AND CHIEF EXECUTIVE OFFICER


If the costs of a new intervention far exceed the benefits, or if patients cannot get access, we’ve failed – as a system – to provide value. Conversely, when we see benefits that far outstrip costs, we can be confident that we are moving the health system in a direction to higher value, with better health and lower costs.

Understanding that balance has never been more critical. The United States spends $3.3 trillion on health care every year, or 18 percent of the nation’s gross domestic product (GDP). That’s about equal to the entire GDP of Germany. Among the primary drivers of this spending are hospital care (32 percent); physician and clinical services (20 percent); retail prescription drugs (10 percent); and other health, residential, and personal care services (5 percent). We have a responsibility to make sure that those dollars are spent wisely and to define what we – as a company and as a part of the health care system – believe is a good investment in the health of the nation.

Celgene’s Value and Innovation Framework Report is an effort to help meet that responsibility. We have developed a framework that outlines our approach to value and defines our role as a driver of value.

 “We have a responsibility to define what we believe is a good investment in the health of the nation.”

Though spending on biopharmaceutical products remains a relatively small piece of the overall health care environment, the biopharmaceutical sector has had an outsized impact on outcomes, and we are proud of our role in a therapeutic revolution that has cut the cancer death rate by 25 percent since 1991. While overall spending on biopharmaceutical products has indeed increased over the years, it has contributed to significant improvements in health outcomes. In fact, one study found that over 70 percent of recent life expectancy growth is due to the increased use of medicines.

Even with the increasing innovation coming from the biopharmaceutical sector, there are signs that drug spending is stabilizing. In 2017, per-person spending on prescription drugs rose just 1.5 percent across plans covering employees and their families, less than half of the increase reported in 2016 and the lowest increase in 24 years of tracking drug-trend data. Another study found that after accounting for rebates and discounts, spending growth on prescription drugs in the United States slowed to 0.6 percent in 2017.

But we cannot simply proclaim successes, declare that we have provided value, and avoid further discussion. Instead, we must start with a clear definition of our goals and a fair-minded examination of our impact at every level of the health care system. This report is evidence of our commitment to evaluating our performance as “value drivers” so that we can continually refine our role in the virtuous cycle of innovation.

To learn more about how Celgene defines value and measures it through medical innovation, read the 2018 Value and Innovation Framework Report.

Pancreatic cancer is once again an area of focus at this year’s American Society of Clinical Oncology (ASCO) Annual Meeting in Chicago. New research is increasingly important as estimates show that the mortality rate of pancreatic cancer could surpass that of breast and colorectal cancers by 2030 in some countries. Celgene is at the forefront of the fight against pancreatic cancer, and at this year’s ASCO conference, new data will continue to expand our understanding of emerging investigational treatments.

Celgene continues the fight against pancreatic cancer through our commitment in advancing research, our collaboration with advocacy groups and our support to patients.

Some look. We envision.

Celgene is committed to advancing research to help change the lives of patients with pancreatic cancer. In 2017, more than 20 percent of our revenue was reinvested into R&D, one of the highest rates in the industry.

Part of our research aims to inform today’s treatment choices in pancreatic cancer. Given the availability of more treatment options for patients with metastatic pancreatic adenocarcinoma, it is time to develop a treatment plan for patients. Celgene is contributing to this important discussion by helping physicians and patients make informed treatment decisions. With an eye toward the future, we are also conducting research and collaborating with researchers around the world on 91 ongoing investigational trials that combine novel agents with the foundation of approved Celgene therapies. These trials involve more than 40 unique novel compounds across more than 30 mechanisms of action and target enrollment of more than 4,500 pancreas cancer patients.

Celgene: Your partner in the fight against pancreatic cancer.

Some hear. We listen.

Celgene collaborates with patient advocacy groups to bring hope to the fight against pancreatic cancer. In partnership with 29 international patient groups, Celgene created the first-ever World Pancreatic Cancer Day in 2014 and continues to grow the event. Celgene also supports events such as Purple Stride Walks in the United States, the European Multi-Stakeholder platform on Pancreatic Cancer in November 2014, 2015 Pancreatic Cancer Forum in Milan and grants to help transport patients to their treatment appointments through the CancerCare GetYouThere program.

Some touch. We feel.

Celgene is dedicated to offering compassion and support to patients with pancreatic cancer and those who care for them. To help them, Celgene developed NavigatePanc.com, a personal pancreatic cancer information center. The site provides information about the disease, clinical trials, support groups, finances and communication and allows patients and caregivers to create their own online libraries of relevant information. Celgene also recognizes that pancreatic cancer patients often have special nutritional needs due to compromised pancreatic function. Our response: a source for recipes and meal planning. Lastly, we are committed to increasing the awareness of pancreatic cancer in the healthcare community.

Pancreatic Cancer: Cooking. Comfort. Care.

We support all who fight pancreatic cancer.

Celgene is committed to providing information and support to people with pancreatic cancer, and their loved ones, to help them in making informed decisions throughout their journey.

To learn more:

The cost and value of medical innovation in oncology is one of the hot topics on the agenda for this year’s American Society for Clinical Oncology Annual Meeting (ASCO). One cancer that has seen an increase in relative survival rates over the past decade is multiple myeloma. So it makes sense that multiple myeloma is at the center of a debate at ASCO on the cost and value of new therapies.

As one of the participants in that debate, Dr. Rafael Fonseca, a hematologist, oncologist and chair of the Department of Internal Medicine at Mayo Clinic in Arizona, will argue that society can’t afford not to provide patients with multiple myeloma access to the best care possible. In this Q&A, Fonseca shares his views about the affordability of cancer therapies, why many doctors hold onto the notion that medications are too expensive and the implications for future multiple myeloma treatment.

DR. RAFAEL FONSECA FROM THE MAYO CLINIC IN ARIZONA BELIEVES THAT SOCIETY CAN’T AFFORD NOT TO PROVIDE PATIENTS WITH MULTIPLE MYELOMA ACCESS TO THE BEST CARE POSSIBLE.

DR. RAFAEL FONSECA FROM THE MAYO CLINIC IN ARIZONA BELIEVES THAT SOCIETY CAN’T AFFORD NOT TO PROVIDE PATIENTS WITH MULTIPLE MYELOMA ACCESS TO THE BEST CARE POSSIBLE.

In the debate, you will argue that we can’t afford not to provide patients with access to the right treatment for them. How did you come to that conclusion?

“Over the past decade, I’ve witnessed so many patients with multiple myeloma increasingly beating the odds for survival. So I wanted to know what exactly was responsible for this. After some research, I concluded—as many of my colleagues have also—that it was the new medications. These innovative therapies provide tremendous value to our patients and society.”

When you discuss this topic with your fellow oncologists, what is the most compelling evidence supporting your position?

“I usually take a stepped approach to presenting my point of view. I ask them to consider the progress that we’ve made in survival in cancers like multiple myeloma and what they have seen in their own patients. I help them understand the value by walking them through all the new therapies that those improvements are attributed to. You can’t just look at the price tag of a specific medication, which they often focus on most.”

The opposing position is that patients and society cannot afford multiple myeloma therapies. Why don’t you believe that argument?

“The data don’t support the argument. One study found that 98 percent of patients paid $50 or less to fill their prescriptions in 2017. While that could be a hardship for some people, it is far different than the list prices of thousands of dollars that make headlines. So we need to talk about what patients are paying in the real world and what’s best for our patients.”

“Beyond that, there are the ethical considerations. Doctors should prescribe the medications they believe will benefit their patients the most.”

Why do doctors continue to say that new cancer therapies are unaffordable if the data suggest they aren’t for most patients?

“I feel like most cancer doctors are concerned about the cost of prescription medications out of their sense of compassion and responsibility for their patients. They see their role as treating patients responsibly. Prescribing a therapy that may cost them thousands seems inconsistent with that mission.”

“But they are so busy caring for patients that they don’t have the time to research the real world data about what patients actually pay for their prescriptions. As we see in other areas of discourse, facts matter. I believe that misunderstood empathy and baseless rhetoric can have real-world consequences for patients.”

Everyone agrees that today’s cancer treatments are simply not good enough and that innovation is key to improving cancer care.

Have you ever had a patient —or many—who could not access treatments that you prescribed?

“I cannot think of a single patient who could not access a medication due to financial reasons. I’ve had patients who have chosen other treatment options but for other reasons—never financial. In a few instances, we have had to go above and beyond to get them financial help from the manufacturer or non-profit groups. But those cases are the exceptions, not the rule.”

What do those on the other side suggest should be done about the affordability of multiple myeloma care and what are the potential consequences?

“When we say that new therapies are too expensive, what we’re doing is calling for price regulations. But without a doubt in my mind, those regulations will kill innovation. Medical innovation is a high-risk, high-reward endeavor. We should not fool ourselves into thinking that there won’t be consequences; we’ll have fewer new treatments for our patients as a result.”

Is there common ground in this debate over the value of multiple myeloma care that can be used to move forward?

“There is plenty of common ground. I think today’s cancer treatments are simply not good enough and that innovation is key to improving cancer care. So we should make sure that we do not hinder that innovation.”

“Most cancer doctors also agree that clinical trials should be as fast as possible without sacrificing safety, so they cost less and lead to faster approvals. And I think that we all think patients should have access to the best treatment options but have different ideas on how to provide that access.”

To learn more about the how medical innovation has improved the treatment of multiple myeloma, read “A Decade of Progress in Multiple Myeloma, and More to Come.”

Dr. Fonseca has received speaker fees, advisory board fees, travel support in connection with consulting services, and research support from Celgene.

An estimated 1.5 million Americans are affected by lupus, and each of these patients has a different story to tell. This inflammatory disease — in which a patient’s immune system begins attacking healthy organs and cells — has many different symptoms and affects each person differently. Some people with lupus have a few mild symptoms, but others can experience many symptoms and severe complications.

In this video produced for this year’s Lupus Awareness Month (May), we asked several patients to share how this complicated, incurable disease affects their daily lives, what they want others to know about their condition, and how they have learned to manage their symptoms.

Celgene wants to thank the Lupus Research Alliance for their partnership in the making of the video.

To learn more about how advances in lupus research are leading to potential new treatment options, read “Genetic Research in Lupus Offers New Lines of Attack.”

In 2017, California’s state health insurance exchange became the first to implement caps on what insurers could charge patients for a prescription medication, topping them at $250 per month, in an effort to protect the chronically ill from ever-increasing insurance cost sharing. While some critics argued that caps would substantially increase pharmacy spending and premiums for everyone, several studies suggested otherwise.

GABRIELA DIEGUEZ, A PRINCIPAL AND CONSULTING ACTUARY WITH MILLIMAN, DID NOT SEE CALIFORNIA INSURERS EXPECTING MUCH IMPACT ON SPENDING OR PREMIUMS FROM COST-SHARING CAPS.

GABRIELA DIEGUEZ, A PRINCIPAL AND CONSULTING ACTUARY WITH MILLIMAN, DID NOT SEE CALIFORNIA INSURERS EXPECTING MUCH IMPACT ON SPENDING OR PREMIUMS FROM COST-SHARING CAPS.

Now, California’s insurers have released their cost projections for 2017, the year that the cost-sharing caps went into effect. The data reveal that insurers did not project much, if any, change in spending or premiums due to the patient out-of-pocket caps, according to an analysis by the actuarial firm Milliman.

“If insurers thought that the sky was falling, we would have seen it in their projections,” said Gabriela Dieguez, a principal and consulting actuary with Milliman and the lead author of the report. “But they didn’t seem to be anticipating spending to grow disproportionately.”

Dieguez and colleagues compared the change in pharmacy spending projections from insurers in California to those in other states without caps. Not only did California insurers not project higher prescription spending increases between 2015 and 2017 than did other states, but their projections actually came in about 1 percent lower for people who buy their own insurance and 3 percent lower for those who get their insurance through a small employer.

Cost Sharing Caps

Some have worried that insurers might raise premiums substantially to guard against any losses from the caps. But this doesn’t seem to be the case, according to the Milliman analysis, which estimated that premiums increased by only about 1 percent for average members.

That relatively small increase leads to significant savings when an innovative therapy for a chronic disease is needed. Dieguez and colleagues projected annual savings of $586 per family member for families that include someone with blood cancer and $683 per family member for those including someone with rheumatoid arthritis.

Savings Due To Cost-Sharing Caps

The findings will help California and other states who have passed similar legislation understand the impact of their caps. Delaware, Louisiana, Maine, Maryland, Montana, New York and Vermont have all limited how much insurers can ask patients to pay for their prescription medications.

“While several states have regulations that limit cost sharing for prescription medications, we chose California because its large insured population provided a credible basis for our analysis,” Dieguez said.

If insurers thought that the sky was falling, we would have seen it in their projections. But they don’t seem to be anticipating spending to grow disproportionately.

The analysis will also inform states who are looking to introduce such legislation, including Connecticut, Illinois, Kansas, Kentucky, Massachusetts, Michigan, Mississippi, Nevada, New Jersey, Ohio, Oregon, Pennsylvania and Washington.

While these numbers are based on projections from insurers, the true impact of the caps on prescription spending and premiums will be revealed when California’s insurers release the final data for 2017 later this year.

“We’re very much looking forward to those data so we can see if the caps made as small of an impact on spending and premiums as the insurers projected,” Dieguez said. “Many people are following the California case closely.”

To learn more about how states are taking action to improve patient access, read “Protecting Patients from Higher Cost Sharing.”