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While members of Congress debate healthcare legislation, rheumatologists say many of their patients struggle to afford everything from generic drugs to insurance copayments for physical therapy.
“It’s a mess. The cost of prescriptions and the rationale for those rising costs in the U.S. right now—it’s just a mess,” says James R. O’Dell, MD, Stokes-Shackleford Professor of Medicine, vice chair of internal medicine, and chief of the Division of Rheumatology at the University of Nebraska Medical Center in Omaha. “There are several areas where it is problematic and makes no sense at all.”
Soaring Ever Higher
Healthcare costs keep rising. The Centers for Medicare and Medicaid Services (CMS) estimates that U.S. prescription drug spending grew 9% in 2015 to $324.6 billion, and out-of-pocket spending by patients for healthcare costs grew 2.6% to $338.1 billion in the same year. The CMS projects that total national health expenditures will soar 5.6% each year between 2016 and 2025.1
While acknowledging that biologics—an essential treatment for many patients with inflammatory diseases, such as rheumatoid arthritis (RA)—are expensive to produce compared with synthetic drugs, their costs seem to be rising dramatically, says Dr. O’Dell.
“My patients used to be able to use a TNF [tumor necrosis factor] inhibitor for about $8,000–10,000 a year, but the cost is now $50,000 a year—less than 20 years later,” he says. Drug pricing is often murky, but one retail drug price comparison website, www.goodrx.com, lists prices for one carton of four self-injectable doses of etanercept (Enbrel) ranging from $4,539–4,788. The recommended dosage for adults with RA generally is one injection per week, so the retail price for a year’s supply of this drug is approximately $54,468. What patients actually pay out of pocket for their medications depends on their individual insurance plans, as well as potential discounts, coupons and copay assistance programs that some manufacturers offer. “There is not much transparency in what the costs really are—or what the drugs even cost to produce—and that is another part of the issue.”
Will Biosimilars Help?
Biosimilars, biologic products designed to be highly similar to an approved reference biologic according to the Food and Drug Administration (FDA), are coming on the market, but they do not yet offer much savings. The FDA has approved biosimilars to etanercept, infliximab and adalimumab.
“Prices for biosimilars are not nearly as aggressive as we had hoped: about 10–15% lower than the reference product,” says Sheila Arquette, RPH, executive director of the National Association of Specialty Pharmacists in Alexandria, Va. Some reference biologics manufacturers are increasing rebates to pharmacy benefit managers and large health insurance plans to keep their costs down, but this strategy may preclude them from including the biosimilar on their formularies. Rebates may not be passed along as savings to the patient at the point of sale, she says.