AMCP CEO looks at the complex situation surrounding the cost of prescription drugs

As leaders of the Alexandria, Virginia-based Academy of Managed Care Pharmacy (AMCP) note on their website, “AMCP is the professional association that helps patients get the medications they need at a price they can afford. AMCP’s diverse membership, including pharmacists, physicians, nurses, and life sciences and biopharmaceutical professionals, use their expertise in clinical evidence and economics to optimize medication benefit design and population health management and help patients receive cost-effective and safe medications and other drug therapies. AMCP members improve the lives of nearly 300 million Americans covered by private and public health plans, pharmacy benefit management companies, and new care models. AMCP advocates at the national and state levels for the development and application of evidence-based medication use strategies that increase access to medications, improve patient and population health outcomes, and ensure the wise use of health care dollars.”

And they point out that their mission is explicitly this: “The practice of managed care pharmacy applies clinical and scientific evidence to support the appropriate use of medications to improve patient and population health outcomes while optimizing the use of limited health resources.” And regarding strategic priorities, AMCP leaders state: “As a professional association, AMCP is a leader in getting patients the medications they need at a price they can afford—and each year we seek to further strengthen our efforts, which are reflected in our strategic priorities. AMCP’s strategic priorities,” they add, “are designed to provide flexibility in the face of the ever-changing healthcare landscape and will be adjusted and refocused based on the needs of our members and the patients they care for.”

Earlier this summer, Healthcare Innovation's Editor-in-Chief spoke with Susan Cantrell, RPh, MHL, CEO of AMCP, to discuss some of her organization's key initiatives and focus areas. Below are excerpts from that interview.

Tell me something about how your club is organized?

We are an individual membership association and have been in existence since 1988. The Academy of Managed Care Pharmacy was founded by a group of eight people from the pharmaceutical industry who worked as pharmacy benefit managers in the 1980s. We have about 8,000 members nationwide; our members include pharmacists, but also some doctors, nurses and others. We are all focused on managing pharmacy benefits for 300 million Americans.

And at AMCP, we have a patient-focused mission: to improve healthcare by ensuring patients have access to high-quality, effective medicines – and ensuring patients get the medicines they need at an affordable price.

You might think your company focuses exclusively on pricing?

This is a common misconception by AMCP. While our members consider economic factors as they influence decision-making, the overarching goal is to ensure patients receive the therapies they need at an affordable price. When I started this work eight years ago, a therapy that could cost $200,000 was exorbitant at the time; today our drugs cost seven figures. Our work has always been important, but it is more important now than ever as prescription drug pricing changes over time.

How does the US healthcare system manage to balance costs and health equity?

Don't we wish we had a cure-all for this? We're now talking about the class of drugs called GLP-1 receptor agonists. [widely known under their commercial brand names, Wegovy, Ozempic, etc.]. Should Medicare continue to cover the cost of taking these drugs after the first year? That sounds great at first. But many patients who were previously uninsured become Medicare-eligible. So that widens the drug gap. As just one example of the potential policy complications, let's say you're insured through a Blue Cross plan through your employer and then you switch to Medicare at age 65: Medicare Part D would continue to cover that drug if you took it for a year beforehand. But what about the large portion of the population that is uninsured or underinsured? Balancing cost and comprehensiveness is exactly what we're focused on. We believe our members play an important role in that. We know there's a prescription abandonment rate of over 30 percent, which is when a prescription is filled but not picked up; and that rate is far higher among minorities. So we're trying to bring that percentage down through the work of our members.

Are there some things we could do as a health care system to address the policy/equity issues?

Yes, it is easier in certain countries like the UK where pharmacoeconomics is controlled in one place. But all is not lost: there is a movement to pay for value in pharma, particularly for these expensive therapies. A fundamental element is to ensure that there is evidence to support these therapies in the real world. But sometimes that evidence is not as solid as we would like, so how can we get the information to do that? Value-based contracting is one solution that can help in this area; and our AMCP members have done innovative work in this area.

One example in this regard is a bill we've been working on with Representative Brett Guthrie of the House Energy and Commerce Subcommittee. It's called the Medicaid Value-Based Purchasing Act of 2023, also called the MVP Act. We've been working with him on it. It would help eliminate one of the challenges to value-based purchasing of drugs under Medicaid, which is the Medicaid best price requirement. If manufacturers and payers have an agreement that the cost of the drug will be reimbursed if it doesn't achieve the intended outcomes in a population, that could effectively be viewed as zeroing out the Medicaid best price if there was a reimbursement, if you will. So allowing multiple best prices under Medicaid would codify certain practices in law and help remove a barrier to innovative contracting under Medicaid.

The first two products for gene therapy in sickle cell disease are now on the market. That's an example of where this could be applied by removing a barrier to innovative contracting. Fortunately, we've gotten some regulatory relief on that. But this would codify that into law.

How will the work of your organization evolve over time?

We've focused a lot of energy on the multimillion-dollar therapies. And then there are the obesity drugs, which don't necessarily require huge investments, but the population is huge, so the impact on health care spending could be huge.

What would you like to see in such a situation?

Our position is that health insurers need the flexibility to make these decisions. Health insurers rely on expert panels in the form of pharmacy and therapeutic committees to review the available pharmacoeconomic evidence and make the right decisions for their patients. And employers have a vested interest in doing so. Government mandates and uniformity will not solve the problem. We really advocate for flexibility to meet the needs of the population.

Does it seem arbitrary if two consumers receive different results from their health insurance regarding coverage (approval or denial) for the same medication?

This is the world we live in. And this is the US healthcare system as it currently stands. There is a lack of uniformity.

So forcing complete harmonization would not be the right approach?

When we look at affordability, I don't think so. Our position has always been that you have to tailor the benefits and the design of the benefits to the population; and the needs of different populations are different. Simply paying more and paying for everything is not the reality.

How should healthcare leaders think about all this?

Our organization does a very good job of looking at the different stakeholders involved that could potentially be part of the solution. For capital-intensive therapies, we've held two partnership forums, invitation-only working meetings where we bring together stakeholders, including patient representatives. And on the capital-intensive therapies, we bring together multiple stakeholders. I think they should be thinking about multi-stakeholder solutions. It's about sharing the burden of affordability across the system. That's how we need to look at it, I think.

Would you like to add something else?

On the topic of health inequalities, at the beginning of our work in this area, we published an article in our journal in November 2020 outlining four imperatives for managed care pharmacy. [“Reducing disparities in medication use: Responding to managed care pharmacy’s imperatives,” Journal of Managed Care Pharmacy, July 1, 2024] The first imperative is to generally recognize that there is racism in the health care system and inequities are part of the problem. So we've worked to raise awareness among our members. And we've also looked at benefit design and cost-sharing. Cost-sharing is a well-intentioned element of benefit design, but in today's environment, cost-sharing can be a barrier for patients. The Inflation Reduction Act has an element that addresses this. One big thing we've been advocating for is collecting and analyzing data on this issue. For years, especially on pharmacy bills, race and ethnicity weren't even captured. So that's another part of our platform: how do we make sure we get the data to address inequities? Medication adherence is also a big issue, with inequities by race, ethnicity, and socioeconomic status; that's going to be a priority for our organization, but fortunately we're addressing that.

Also, in terms of overall U.S. health spending, one factor is innovation in pharmaceuticals. We shouldn't lose sight of that: the fact that we now have gene therapy for sickle cell anemia, that we have drugs that can treat obesity – there is remarkable innovation happening, and we don't want payment policy to stifle innovation. But I saw a number from Reuters that said that in 2021, the average cost of an FDA-approved novel therapy [Food and Drug Administration]was $180,000, then $220,000 in 2022, and $230,000 in 2023. And when we think about balance, we must not hinder innovation.