Providers poised to pounce on midterm results for pharma beatdown

(Updated at 4:20 p.m. ET)

The soon-to-be Democrat-led House of Representatives and the Trump administration are poised to square off against the pharmaceutical industry as they look to rein in drug prices, and providers are more than willing to join the fight against their common adversary.

Democrats gained control of the House in the midterm elections Tuesday night for the first time in nearly a decade, while the Republicans retained the Senate majority. A split House and Senate likely means that most of the sweeping policy changes related to an overhaul of the Affordable Care Act or implementing a single-payer system are off the table until 2020. Instead, lawmakers, the Trump administration and healthcare lobbyists can focus on areas like drug pricing, transparency and cost control, experts said.

"Now that Democrats control the House, they will push harder on prescription drug costs," said Tracy Carter, vice president of government relations for Cleveland, Ohio-based MetroHealth. HHS Secretary Alex Azar "is lasered in on that. They believe it is out of control and there has to be a better solution for the patient. We in the provider community would like to be in the room to talk about that."

The administration has made some strides on the pricing and transparency front. Although not all of President Donald Trump's promises have come to fruition.

Late last month, Trump announced a proposal to tie prescription drug rates paid by Medicare Part B to the lower prices paid in other advanced countries. The mandatory proposal would save the government and Medicare beneficiaries an estimated $17.2 billion over five years.

About a week later, HHS said it would move ahead with its plans to cap the prices drugmakers can charge hospitals that participate in the 340B drug discount program.

In his drug-pricing blueprint, Trump advocated bolstering competition by introducing more generic and biosimilar drugs, allowing private plans to negotiate discounts for Medicare beneficiaries, creating incentives to lower list prices and reducing consumers' out-of-pocket spending. But the administration has walked back its promise to allow the government to negotiate drug prices directly with manufacturers.

While the House may hold more hearings on drug pricing and how the Trump administration's proposals have fallen short, those efforts aren't expected to lead to price controls, Height Capital Markets wrote in a note to clients.

"I think they can all agree on beating up pharma, and pharma never seems to have too much of a problem with that, as long as not too much happens," said Drew Altman, president and CEO of the Kaiser Family Foundation.

The talk about collaborating to curb drug prices may be just that—talk, Altman said.

"I think they'll have more rhetorical agreement then agreement on anything significant," he said. "That will break down into the usual partisan logjam, and in a presidential campaign time, just resistance to the idea of anyone giving anyone else a victory."

A Democrat-controlled House gives generic-drug manufacturers more support to help pass the Creates Act, which aims to help more generic drugs get to market by removing some barriers pharmaceutical companies use to limit access to samples of branded products, according to Height Capital Markets. Seventy-one percent of drugs covered under Medicare Part D—2,009 in total—are made by just one manufacturer, according to an analysis from PricewaterhouseCoopers.

Single-source drug spending rose at an average annual rate of 25%, a total of 285% from 2010 to 2016, according to a Blue Cross and Blue Shield Association study. These patent-protected drugs made up 63% of total drug spending in 2016, up from 29% of total spending in 2010, despite the fact that they account for less than 10% of total prescriptions filled.

The Pharmaceutical Research and Manufacturers of America said it couldn't speculate on what Congress may do, but it remains focused on "advancing market-based reforms that address misaligned incentives in the biopharmaceutical supply chain." The trade group said that although the rate of pharmaceutical price increase slowed last year, patients' out-of-pocket costs continue to skyrocket.

Providers have indicated that they do not want to wait for Congress to act. A group of health systems, spearheaded by Intermountain Healthcare, Ascension, SSM and Trinity, formed a generic-drug company this year that seeks to stabilize the supply of generic medications like sterile injectibles that hospitals rely on and ultimately lower their cost. About a third of the nation's hospitals either committed to Civica Rx or have expressed interest, said Dr. Marc Harrison, CEO of Intermountain.

"I can tell you that Civica Rx's not-for-profit model does not require congressional action to be successful, but that we have received tremendous bipartisan encouragement from elected officials and from regulatory agencies to continue with our efforts to make essential generic medications available and affordable to everyone," he said. "Civica Rx and its governing members are working through how Congress might be even more helpful, but are still early on in that thinking."

Rep. Lloyd Doggett of Texas has been one of many critics of Trump's drug-pricing strategy, claiming that it hasn't gone far enough. Doggett, who helped found the House Democrats' Affordable Prescription Drug Caucus, is expected to head the House Ways & Means Committee's health subcommittee in the new Congress, which would position him to influence that strategy.

There may be more pressure to tweak the drug rebate model, given that a third of drug spending is in the pharmaceutical supply chain, said Ben Isgur, who leads PwC's research institute.

But Wall Street didn't seem too concerned about the threat of drug-pricing overhauls as the pharmaceutical stocks increased Wednesday. Shares of Gilead, Pfizer, AbbVie and Amgen stock traded up more than 3%.

On the Medicaid expansion front, Idaho, Nebraska and Utah are on track to expand the public health insurance program for low-income Americans. And Democratic victories in the Kansas, Maine and Wisconsin gubernatorial races set the table for Medicaid expansion in those states. The six states could potentially add at least a half-million beneficiaries to the rolls.

"If there was any winner in the election, it was healthcare coverage," Isgur said. "It's no surprise. Many voters said that healthcare coverage is not affordable so they have to find other ways to get it through Medicaid or the exchanges."

States still have a lot of control regarding Affordable Care Act implementation through skimpier association health plans, reinsurance programs and Medicaid work requirements.

MetroHealth's Carter said she expects Medicaid work requirements to be implemented in Ohio soon, following the lead of others states like Wisconsin.

"We advocate against any restriction that could prevent individuals from accessing coverage in a timely fashion," Carter said.

Medicaid expansion is vital in easing the burden of uncompensated care on the system, said Ceci Connolly, Alliance of Community Health Plans' president and CEO.

"We are hopeful the new Democratic House will work to ensure we do not see further erosion of the Affordable Care Act and will work constructively with the administration to tackle high drug prices," Connolly wrote in an email to Modern Healthcare.

The Association for Community Affiliated Plans lauded the prospect of expanding Medicaid coverage.

"Expanding health coverage improves access to care, leads to better health outcomes, lowers uncompensated care for healthcare providers, and helps people with low incomes stay out of crushing medical debt," ACAP CEO Margaret Murray said in a statement.

Medicaid expansion and bolstering MetroHealth's managed-care programs have helped the system trim nearly 30% in spending as well as boost outcomes, according to Carter.

"Coverage works," she said.

While Congress likely won't be able to muster the political will to overturn the ACA, a Texas-led lawsuit is a "wild card" looming over the industry's head, said Chip Kahn, the president and CEO of the Federation of American Hospitals.

Twenty Republican state attorneys general, led by Ken Paxton of Texas, are seeking a preliminary injunction to halt enforcement of the law effective Jan. 1. They argue that the ACA is unconstitutional because it no longer falls under Congress' taxing authority since the GOP eliminated the individual mandate penalty.

Still, the underlying forces of the healthcare industry remain. Healthcare costs are increasing significantly faster than inflation, which is eating into state budgets, business profits and consumer spending. Those forces combined with healthcare outsiders creeping into the picture will exert more pressure to develop a more efficient system.

Medicare spending is increasing at an unsustainable pace, said Michael Abrams, managing partner of healthcare consultancy Numerof & Associates.

Debate related to which political party has an edge distracts from what should be the ultimate goal—addressing the core factors of high healthcare costs and lagging outcomes, he said.

"If we just talk about partisan advantage we will continue to spin our wheels and two years from now we will not be any closer to a solution," Abrams said. "We will be closer to the failure of our healthcare system."