SEOTEMBER 10, 2024

What’s Happening in Healthcare: Q4 2024

In this quarter’s edition, we take a detailed trip around the healthcare industry and find out what’s happening with:


  • GLP-1 utilization and the role of PBMs

  • Price cuts from the IRAWords we’re happy to see go from healthcare lingo

  • A German manufacturer offering 92% discounts

  • The rapid rise of infusion centers across the country in 2024


Let’s dive in…

In this quarter’s edition, we take a detailed trip around the healthcare industry and find out what’s happening with:

  • GLP-1 utilization and the role of PBMs

  • Price cuts from the IRA

  • Words we’re happy to see go from healthcare lingo

  • A German manufacturer offering 92% discounts

  • The rapid rise of infusion centers across the country in 2024

Let’s dive in…

GLP-1s, Employers, and the role of utilization

With the rise in popularity of GLP-1 agonists, plans, employers, and their PBMs are weighing coverage options against rising demand and fluctuating costs. 


A recent study found 71% of employers are taking their PBM’s recommendations into account when it comes to covering GLP-1s for weight loss. 


Among employer-sponsored insurance plans, around 34% cover both diabetes and weight loss treatment with a GLP-1.

With the rise in popularity of GLP-1 agonists, plans, employers, and their PBMs are weighing coverage options against rising demand and fluctuating costs. 

A recent study found 71% of employers are taking their PBM’s recommendations into account when it comes to covering GLP-1s for weight loss. 

Among employer-sponsored insurance plans, around 34% cover both diabetes and weight loss treatment with a GLP-1.

8.9% of total annual claims are for GLP-1 drugs for weight loss.

8.9% of total annual claims are for GLP-1 drugs for weight loss.

1 in 8 Americans have used a GLP-1 agonist.

1 in 8 Americans have used a GLP-1 agonist.

41% discounts on list price are being offered for
GLP-1s for weight loss

41% discounts on list price are being offered for GLP-1s for weight loss

-54% discounts are being offered for treating type-2 diabetes.

-54% discounts are being offered for treating type-2 diabetes.

Utilization management is being leveraged heavily to control costs as demand soars. PBMs are leveraging competition to bring down net costs for employers. It’s also been noted that access and rebates may be impacted by step therapy or BMI requirements. Other considerations for employers include the long-term health complications associated with obesity, lending to the increasing adoption of GLP-1s among employer-sponsored plans. 


Rebates and benefit design are featured prominently across the discussion, showing the importance of PBMs and their ability to drive competition in the market that brings down net costs for plan sponsors and CMS.

Utilization management is being leveraged heavily to control costs as demand soars. PBMs are leveraging competition to bring down net costs for employers. It’s also been noted that access and rebates may be impacted by step therapy or BMI requirements. Other considerations for employers include the long-term health complications associated with obesity, lending to the increasing adoption of GLP-1s among employer-sponsored plans. 

Rebates and benefit design are featured prominently across the discussion, showing the importance of PBMs and their ability to drive competition in the market that brings down net costs for plan sponsors and CMS.

IRA price cuts become clear

Quick reminder: these price cuts will come into effect in 2026. In 2027, Medicare will add another 15 drugs to the list and negotiate their prices down.


Here's an overview of who and what's been reduced by the Inflation Reduction Act and Medicare drug price negotiations (scroll to the right to see more).

Quick reminder: these price cuts will come into effect in 2026. In 2027, Medicare will add another 15 drugs to the list and negotiate their prices down.

Here’s an overview of who and what’s been reduced by the Inflation Reduction Act and Medicare drug price negotiations.

Manufacturer

Johnson & Johnson

Johnson & Johnson

Johnson & Johnson

Bristol Myers

Eli Lilly

Merck

Amgen

AstraZeneca

Novo Nordisk

Novartis

Drug

Xarelto

Imbruvica

Stelara

Eliquis

Jardiance

Januvia

Enbrel

Farxiga

Fiasp

Entresto

Primary Use

Anticoagulant

Blood cancer treatment

Infusion immunosuppressive drug

Anticoagulant

Type 2 diabetes treatment

Type 2 diabetes treatment

Autoinjector, arthritis, plaque psoriasis

Type 2 diabetes, heart failure risk reduction

Insulin injectable

Heart failure risk reduction

2023 Price

$517

$14,934

$13,836

$521

$573

$527

$7,106

$556

$495

$628

2026 Price
(Post-negotiation)

$197

$9,139

$4,695

$231

$197

$113

$2,355

$178

$119

$295

Percent
Reduction

62%

38%

66%

56%

66%

79%

67%

68%

76%

53%

It’s time to put these phrases to bed

Becker’s recently asked some CEOs which buzzwords have come to the end of their half-life, so here’s what you should scale back on as we bring 2024 to an end:

Becker’s recently asked some CEOs which buzzwords have come to the end of their half-life, so here’s what you should scale back on as we bring 2024 to an end:

Workforce crisis
Bandwidth
Providers
Burnout 
Population health
Value-based care

German Humira Competitor Offering
92% Discount for Out Of Pocket

German Humira Competitor Offering 92% Discount for Out Of Pocket

Boehringer Ingelheim’s biosimilar will be offered at a steep discount for cash-paying patients through a partnership with GoodRx. The move indicates strong competition is coming to the market with AbbVie’s patent expiration last year.


Other manufacturers entering the market with discounted biosimilars:

Boehringer Ingelheim’s biosimilar will be offered at a steep discount for cash-paying patients through a partnership with GoodRx. The move indicates strong competition is coming to the market with AbbVie’s patent expiration last year.

Other manufacturers entering the market with discounted biosimilars:

Sandoz
Alvotech
Amgen
Fresnius

40%

Humira sales down YoY
at the beginning of 2024

Humira sales down YoY at the beginning of 2024

Infusion Centers Are Opening Across the Country

Kettering Health opens a non-oncology infusion center in Troy, OH.

Kettering Health opens a non-oncology infusion center in Troy, OH.

UC Irvine opens a major cancer center with 40 infusion bays.

UC Irvine opens a major cancer center with 40 infusion bays.

Baystate Health opens an outpatient infusion center.

Baystate Health opens an outpatient infusion center.

IVX Health is planning to open nine infusion centers in Houston, Austin, San Antonio.

IVX Health is planning to open nine infusion centers in Houston, Austin, San Antonio.

Hospitals of Providence opens an infusion center in El Paso, TX.

Hospitals of Providence opens an infusion center in El Paso, TX.

Two infusion centers open in Maui, HI, developed by Hawai'i Specialty Pharmacy and Maui Care Physicians

Two infusion centers open in Maui, HI, developed by Hawai'i Specialty Pharmacy and Maui Care Physicians

Did you know Vista provides technology, strategy, and partnerships that make the buy-and-bill model more effective for infusion center operators?

Did you know Vista provides technology, strategy, and partnerships that make the buy-and-bill model more effective for infusion center operators?

Learn More

Founded in 2018, VistaRx (Vista) provides comprehensive pharmacy data capture and management solutions for a variety of entities in the pharmacy value chain. We utilize custom-coded technology, strategies, and partnerships to help our clients improve operations and reduce dependence on third-party vendors.

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