(Bloomberg) — As Gilead Sciences Inc. touted its $1,000-a-pill hepatitis C cure to investors in a hotel ballroom in San Francisco, a group of about 20 protesters milled outside. "Gilead=Greed," one sign read.
"I'm glad people have the new drugs, but I'm concerned about the prices," said Orlando Chavez, 62, a hepatitis C and HIV counselor and one of the protesters on Jan. 13. He worries that insurers will see Gilead's price and force patients to try a less effective, older and cheaper therapy first, he said.
Chavez has good reason to worry.
Payers face billions of dollars in new drug costs as pharmaceutical companies develop increasingly complex products in the years ahead. Express Scripts Holding Co., Catamaran Corp., Aetna Inc. (NYSE:AET) and CVS Caremark Corp. among others are already pushing back against the high cost of Gilead's drug. They're discussing how to pit similar drugs against each other, refusing coverage for some, or subjecting treatments to more review by outside experts and refusing to pay a premium based on one drug being more convenient to take than another.
Gilead's new drug, Sovaldi, costs $84,000 for a 12-week treatment. Such breakthrough treatments and their stratospheric price tags have "absolutely" caused insurers to reconsider covering high-priced hepatitis, diabetes and other treatments, said Sumit Dutta, chief medical officer of Catamaran, the fourth-biggest U.S. pharmacy benefit manager, or PBM.
"You can't manage exclusively by the techniques PBMs have used in the past," Dutta said by telephone. "We're seeing the shift, where payers are finally going to say, 'It's $84,000, and the other therapy is $50,000 — what am I getting?'"
Stock valuation
For drugmakers and biotechnology companies that have zeroed in on high-priced treatments to replace blockbusters such as Lipitor, the Pfizer Inc. cholesterol drug that once drew more than $12 billion a year before losing ground to generics, the change may affect how shareholders value their stocks, according to Les Funtleyder, a health industry expert and author of the book "Health-Care Investing."
"There's been a feeling among investors that biotech drugs are immune from price competition," Funtleyder said in an interview. "We're getting to where we may have may reached a pain point."
Prescription drugs make up an increasing share of U.S. health care spending. Spending on hepatitis C drugs alone is projected to rise seven-fold from $3 billion a year in 2011 to $21 billion in 2018, according to market research firm Decision Resources Group L.L.C. U.S. drug spending will grow 6.5 percent a year from 2015 to 2022, faster than overall health costs, according to the U.S. Centers for Medicare and Medicaid Services. That's mostly driven by rising prices and a leveling off of generic drug use, according to the report.
Gilead shares fell 2.2 percent to $78.86 at 4 p.m. EST. AbbVie Inc., which is also developing a treatment, declined 2 percent to $46.83.
It will take Gilead three to six months since it was approved Dec. 6 to formalize coverage with payers and PBMs, said Chief Operating Officer John Milligan in an e-mail. In the meantime, most plans are covering it, he said.
When eventually combined with a second drug Gilead is studying, the regimen's price could rise to $100,000 or more per year, compared to what Catamaran says is about $66,000 for the current standard of care.
That's still cheaper than treating complications of hepatitis C, which can lead to liver damage or failure and the eventual need for transplant, said Gilead's Milligan.
"In our conversations with payers, pricing is a consideration, but efficacy, safety and treatment guidelines are equally important," Milligan said.
Tools available
Besides payers already have plenty of tools to push back on costs and force patients to try cheaper medicines first, and they use them, said the drug industry's Washington trade group, Pharmaceutical Researchers and Manufacturers of America. "Typically by the time the patients get through the various steps they need to get to the product, they really do need it," said Lori Reilly, PhRMA's head of policy.
