Billy Tauzin’s $80 Billion Deal

The main objective of the healthcare reform bills being considered is to expand health insurance coverage, especially by reducing the number of uninsured Americans. That goal also benefits the pharmaceutical industry because, with better insurance coverage, people consume more healthcare products and services, including prescription drugs, thus expanding the market for pharmaceuticals. In return for the favor of expanding the healthcare market, the Obama administration has sought concessions from each group who stands to benefit, including insurance companies, hospitals, and pharmaceutical companies. Rather than fight the concessions, the Pharmaceutical Research and Manufacturers of America (PhRMA), under the leadership of president Billy Tauzin, reached an agreement with the Obama administration in June that the pharmaceutical industry would shoulder $80 billion in concessions over 10 years.

What is the composition of the $80 billion? While the precise breakdown has not been disclosed, we can make very rough estimates based on the main provisions in the Baucus bill that reduce pharmaceutical company revenues.

The first is the 50% pricing discount for the drugs Medicare beneficiaries purchase in the so-called “doughnut hole” in Medicare Part D, in which Medicare provides no subsidies for the cost of prescription drugs. The discount would not apply to prescription drug purchases by one of the costliest groups of beneficiaries, the dually eligible beneficiaries who are enrolled in both Medicare and Medicaid. Their drug purchases are always subsidized, so the doughnut hole does not apply to them. Nor would the discounts apply to high-income Medicare beneficiaries who must pay higher premiums in Part B. All other beneficiaries, however, would receive a 50% price discount on their drug purchases in the doughnut hole starting in July of 2010. A rough estimate of the cost of this provision to the pharmaceutical industry is $30 billion over 10 years.

The second is the increase in the statutory rebate rates for brand drug purchases in Medicaid from 15.1% to 23.1%. Rebates for blood clotting factors and for drugs approved for pediatric use only would increase from 15.1% to 17.1%. A rough estimate of the cost of this provision to the pharmaceutical industry is a minimum of $30 billion over 10 years.

A third component is the savings reaped through increased competition as a result of the introduction of follow-on biologics. While provisions relating to follow-on biologics currently are not part of the Baucus bill, provisions similar to those approved in the amended House Energy and Commerce Committee bill and the Senate HELP Committee bill, both of which allow for 12 years of marketing exclusivity, are expected to be included in any final bill. A rough estimate of the cost to the pharmaceutical industry of introducing follow-on biologics is $7 billion over 10 years.

The fourth component is a new fee of $2.3 billion per year that will be assessed on the pharmaceutical industry based upon each company’s market share in sales to public programs, including Medicare, Medicaid, the Veterans Administration program, and the TRICARE military program. Sales of orphan drugs would be exempt. Companies with annual sales of less than $400 million would receive discounted weights for calculating their sales for the purpose of determining market share, and companies with sales of less than $5 million would be exempt. Fees for 2010 will be based on calculated market share of sales in 2009. At $2.3 billion per year, the total cost to the pharmaceutical industry over 10 years is $23 billion. Moreover, by statute, these fees would not be deductible for US income tax purposes.

Adding these four components together results in a total burden to the pharmaceutical industry over 10 years of $90 billion, $10 billion more than the $80 billion pledged by PhRMA’s Billy Tauzin.

Cutting Benefits in Medicare: Truth or Fiction?

One of the flash points in the debate over healthcare reform legislation is whether the bills proposed in the House and the Senate would cut the benefits of Medicare beneficiaries. Of course, nothing can mobilize a group of senior citizens more quickly than a proposal to cut their benefits, and opponents of healthcare reform have claimed that the bills coming out of the House and Senate do just that. Are these claims valid?

The short answer is yes, at least for some beneficiaries who are enrolled in Medicare Advantage plans, which are private insurance company plans that receive Medicare dollars to deliver a package of benefits to replace Medicare Part A and Part B. One of the most signficant sources of savings in both the House and Senate bills is stems from changes in payments to Medicare Advantage plans.

Originally it was hoped that, by allowing private plans to participate in Medicare, beneficiaries might receive better coordinated care compared to fee-for-service Medicare and, if the private plans were more efficient than traditional Medicare, they might even save money for Medicare. For example, in a given region of the country, if Medicare beneficiaries on average consume medical services that cost the Medicare program $10,000 per year, there is the possibility that a private plan could deliver the same benefits for less than $10,000. If the Medicare program paid the plan $9,750 and the plan could deliver benefits for $9,500, the Medicare program would save $250 and the plan could make an extra profit of $250. To encourage plan participation, however, in recent years, for most areas (rates are actually set on a county-by-county basis), Congress has set the benchmark rates, which are the basis for payments to the Medicare Advantage plans well above the average per-beneficiary costs Medicare incurs in each area. The way the payment mechanism works is that plans bid against the benchmark rates for each county. If their bid is below the benchmark, they recieve their bid plus 75% of the difference between their bid and the benchmark, and the remaining 25% is retained by the Medicare program. So if the benchmark is $12,000 and the plan bids $11,000, the plan receives $11,750. According to the rules of Medicare Advantage, plans must use the extra $750 above the benchmark to provide extra benefits to beneficiaries. In this example, therefore, beneficiaries would receive an extra $750 in benefits. Compared to the regular fee-for-service Medicare program, however, the costs are much higher than the average per-beneficiary costs in each county. In this example, instead of incurring an average of $10,000 in costs, Medicare is paying the plan $11,750. And, while it is true that the beneficiaries in this case receive an extra $750 in benefits, Medicare is paying an extra $1,750 for those benefits. Because they can receive extra benefits, beneficiaries naturally like the Medicare Advantage program, and enrollment has soared in recent years. Now one in every four Medicare beneficiaries is enrolled in a Medicare Advantage plan.

Medicare program payments relative to FFS spending, 2009

In 2009, in comparison with traditional fee-for-service Medicare costs, Medicare is paying Medicare Advantage plans an extra 14%. It is these extra costs that Congress has taregeted for savings. The House bill sets the benchmark rates at 100% of the average per-beneficiary fee-for-service Medicare costs for each county. The Senate bill sets the bechmark rates at the weighted-average bids of each plan. In either case, the savings would be substantial. With lower benchmarks, however, plans will not be in a position to maintain the level of extra benefits they currently provide, so these extra benefits would be cut. Therefore, it is true that these extra benefits would be cut, but the traditional benefits of Medicare Part A and Part B would not be cut.