6 Healthcare Themes for 2016

Dec 29, 2015
Six key storylines of 2015 foreshadow what will be driving the pharmacy benefit conversation in 2016.
  • Cancer
  • Hepatitis C
  • High Blood Cholesterol
  • HIV

In 2015, we demonstrated our ability to take bold action and deliver better patient care. As current and forecasted prescription drug spending reach unsustainable levels, we led the industry with solutions to make prescription drugs more affordable and accessible.

These topics defined the pharmacy benefit landscape and will continue to drive the conversation in 2016:

1. U.S. Spending on High-Cost Medication Reaches a Tipping Point

Our analysis found that an estimated 576,000 Americans spent more than the median household income on prescription medications in 2014. This population of patients grew an astounding 63% from 2013. And the total cost impact to payers from both patient populations is an unsustainable $52 billion a year.

Now, more than ever, plan sponsors need a comprehensive management approach that effectively improves patient care and outcomes while reducing wasteful spending. That’s why Express Scripts launched a suite of solutions to uniquely help clients address the challenge of budget-busting drugs.

2. The $4 Billion Return on a Promise Kept

Last year, we frequently discussed the national cost burden of treating patients with hepatitis C. Never before had a class of medication been priced this high to treat a patient population this large. We made a promise to our clients and patients to work to lower the cost of these medications, and that was a promise that we were proud to keep.

Our Hepatitis Cure Value ProgramSM successfully lowered the cost of curative treatments by nearly 50% in 2015 and created an unprecedented solution for improving patient care and maximizing cost savings.

Because of our initial action, follow-up negotiations will ultimately lower the national spend on hepatitis C drugs by more than $4 billion annually.

3. Significant Value Through Smart Formulary Management

Many therapy classes have more drug choices than ever, with some prescription drugs costing more but delivering no additional health benefit. By opening up access to all clinically superior medications, and excluding a handful of “me-too” products that have no clinical benefit beyond what’s provided by more affordable alternatives, we have leverage to negotiate more effectively with manufacturers and ultimately achieve lower drug prices for the clients and patients we serve.

Since Express Scripts began excluding medications from this formulary in 2014, we have changed the marketplace dynamic. Because drug manufacturers want to avoid the potential of losing market share, we are now able to negotiate even deeper discounts for our clients, while excluding fewer additional medications.

With the National Preferred Formulary, our plan sponsors will save approximately $1.3 billion throughout the year, creating more than $3 billion of total savings for those plans since 2014.

4. Solving the Cancer Care Puzzle

In 2016, the world is expected to pay more than $100 billion for cancer drugs. While some oncology medications are indicated to treat multiple types of cancer, the cost of treatment may not align with its outcomes for various types of cancer.

It’s time to rethink how we pay for cancer drugs, and a revolution in how we do that will be driven by an evolution of solutions we already have.

Express Scripts’ Oncology Care Value Program® (OCV) has a multi-faceted approach to align cost of treatment with its outcomes. The program will focus in 2016 on prostate cancer, lung cancer and renal cell carcinoma. In subsequent years, Express Scripts plans to apply this approach when treating other cancer categories.

The OCV Program takes an integrated approach with specialist pharmacists in our Oncology TRC are experts in treatment, risk, possible side effects and drug interactions. This holistic model provides better patient care and can more effectively manage costs.

5. Appropriate Utilization and Superior Patient Care

When a new class of cholesterol lowering medications – known as PCSK9 inhibitors – was approved earlier this year, Express Scripts protected plans from unnecessary costs by launching the Cholesterol Care Value ProgramSM (CCV).

The CCV Program uses rigorous clinical documentation to ensure access to the right patients, while minimizing unnecessary risks and wasteful spending. By focusing the use of these new drugs to those patients who benefit the most, we have saved our clients hundreds of millions of dollars.

Through collaborative discussions with manufactures of PCSK9 drugs, we were able to include both Praluent® (alirocumab) and Repatha™ (evolocumab) on our National Preferred Formulary.

We’ve shown that the market – when competitive – can deliver fair drug pricing.

6. Championing Access and Affordability

In September this year, Turing Pharmaceuticals made the decisions to hike the price of Daraprim (pyrimethamine) from $13.50 per pill to $750 per pill. This left treatment for toxoplasmosis priced out of reach for people with HIV, pregnant women and others with weakened immune systems. This was unacceptable.

Leveraging our expertise to improve access and affordability to an important medication, we partnered with Imprimis Pharmaceuticals to make a low-cost alternative available to our patients.

Physicians will be able to send a patient-specific prescription for the combination formulation of pyrimethamine and leucovorin to Imprimis, which is now a part of the Express Scripts pharmacy network. Imprimis will compound the two drugs together into an alternative for patients.

We believe this was the right thing to do for HIV patients and others who needed cost-effective access to a Daraprim alternative.


In 2016, through smarter pharmacy, Express Scripts will continue to lead the charge to make prescription drugs more affordable and accessible for our patients and clients.

Wishing you a happy and healthy New Year!

Author Bio

Lab Staff
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