AMCP’s CEO Looks at the Complex Landscape Around Prescription Drug Costs

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

And they note 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 enhance patient and population health outcomes while optimizing the use of limited health care resources.” And, in terms of strategic priorities, AMCP’s leaders state that, “As a professional association, AMCP leads the way to help patients get the medications they need at a cost they can afford – and every year, we seek to continue to strengthen our efforts as represented by our Strategic Priorities. AMCP’s strategic priorities,” they add, “are designed to provide flexibility given the ever-changing health care landscape and adapted and refocused based on the needs of our members and the patients they serve.”

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

Tell me a bit about how your association is organized?

We’re an individual-membership society, and have been in existence since 1988. The Academy of Managed Care Pharmacy was founded by a group of eight individuals in pharmacy who were pharmacy benefit managers back in the 1980s. We have about 8,000 members nationwide; our membership includes pharmacists, but also some physicians, nurses, and others. We’re all focused on managing pharmacy benefits for 300 million Americans.

And we have a patient-focused mission at AMCP: improving healthcare by making sure patients have access to high-quality, effective medicines—making sure patients get the medications they need at an affordable price.

One might be forgiven for assuming that your organization is totally focused on pricing?

That’s a not-uncommon misperception about AMCP. Our members do take into consideration economic elements, as those elements drive decision-making; but the overarching goal is to make sure patients can get the therapies they need at an affordable cost. When I started this job eight years ago, a therapy that might cost $200,000 was exorbitant at the time; today, we have seven-figure price-tag medications. Our work has always been important, but it’s more important now than ever, as the landscape around prescription drug pricing changes over time.

How does the U.S. healthcare system balance the cost issue with the health equity issue?

Don’t we wish we had a silver bullet around that? We’re talking now about the class of drugs called the drugs called the GLP-1 receptor agonists [widely known under their commercial brand names, Wegovy, Ozempic, etc.]. Should Medicare continue to pay for patients to take these drugs even after the first year? It sounds great at the outset. But a lot of patients become Medicare-eligible who were previously uninsured. So that exacerbates the gap in terms of medications. As just one example of the potential policy complications involved, let’s say that you’re covered by a Blue Cross plan through your employer, and then you go onto Medicare at age 65: Medicare Part D would continue to cover that drug if you were on it for a year previously. But what about the large portion of the population that is uninsured or underinsured? Balancing cost and comprehensiveness is exactly what we’re focusing on. We believe there’s an important role for our members in this. We know there’s a 30-plus-percent abandonment rate for prescriptions, where a prescription is filled but not picked up; and that rate is far higher in minority populations. So we’re trying to chip away at that, through the work of members.

Are there a few things we could do as a healthcare system to fix the policy/equity issues?

Yes, it is easier in certain countries, like the UK, where there is a single locus of control around pharmacoeconomics. But all is not lost: there’s been a movement to pay for value in the pharmaceutical space, especially when it comes to these high-cost therapies. One fundamental element is making sure there’s evidence to support these therapies in the real world. Sometimes, that evidence is not as robust as we’d like to see. So how do we extract the information around that? Value-based contracting is one solution that can help in this area; and there’s been innovative work done in that area by our AMCP members.

One example in that regard is a piece of legislation we’ve been working with Rep. Brett Guthrie of the House Subcommittee of Energy and Commerce. It’s called the Medicaid Value-Based Purchasing Act of 2023, nicknamed the MVP Act. We’ve been working with him on that. It would help to remove one of the challenges to value-based purchasing of pharmaceuticals in Medicaid, the Medicaid best-price requirement. If the manufacturer and payer enter into an agreement where the cost of the drug is rebated if it doesn’t achieve the intended results in a population, that could effectively be viewed as setting the Medicaid best price as zero, if there were a refund, if you will. So allowing for multiple best prices in Medicaid would codify certain practices under law, and would help to remove one barrier to innovative contracting under Medicaid.

We’ve had the first two products for gene therapy in sickle cell anemia reach the market now; that’s an example where this could be applied, by removing a barrier to innovative contracting. Thankfully, we’ve had some regulatory relief on that; but this would codify that under law.

How will your organization’s work evolve over time?

We’ve been focusing a lot of energy on the multi-million-dollar therapies. And then along come the obesity drugs that aren’t necessarily high-investment medications, but the population is gigantic, so the impact on healthcare spending could be staggering.

What would you like to see in a situation like that?

Our position has been that health plans need the flexibility to make those decisions. Health plans lean on panels of experts in the form of pharmacy and therapeutics committees, to look at the evidence, the pharmacoeconomic evidence available, and make the right decisions for their populations. And employers have an important stake in this. Government mandates and uniformity won’t solve the problem. We really advocate for flexibility, so that the needs of the population can be considered.

If two consumers receive different health plan results in terms of coverage—approval versus denial—for the same drug—does that seem arbitrary?

That’s the world we live in. And that is the U.S. healthcare system as it is right now. There is a lack of uniformity.

So forcing a complete harmonization would not be the right approach?

If we’re looking at affordability, I think not. Our position has always been that you need to tailor the benefits and benefit design to the population; and the needs of different populations are different. Just paying more and paying for everything is not the reality.

How should health system leaders be thinking about all of this?

One of the things our organization does quite well is looking at the multiple stakeholders involved that might potentially be part of the solution. Per high-investment therapies, we’ve had two partnership forums, invitational working sessions where we bring stakeholders, including patient representatives, together. And in terms of the high-investment therapies, we bring multiple stakeholders together. I think that multi-stakeholder solutions are what they should be thinking about. It’s shared pain across the system to address affordability. We have to look at it that way, I think.

Is there anything you’d like to add?

Per health disparities, at the outset of some of our work in this area, in November 2020, we published an article in our journal in which we laid out four imperatives in 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 acknowledge broadly that racism exists in the healthcare system, and disparities are a part of the problem. So we’ve worked on awareness among our members. And we’ve also looked at benefit design and cost-sharing. Cost-sharing is a well-intended element in benefit design; but in today’s environment, cost-sharing can be a barrier to patients. The Inflation Reduction Act does have an element addressing that. A big thing we’ve advocated for is collecting and analyzing data on this. For years, in pharmacy claims in particular, race and ethnicity were not even collected. So that’s another part of our platform: how do we make sure to get the data for addressing disparities? Medication adherence is also a big issue, with disparities by race, ethnicity, and socioeconomic status; that will be a priority for our organization; but thankfully, we’re addressing that.

Also, in terms of overall U.S. healthcare expenditures, one of the factors there is innovation in the pharmaceutical space. 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 manage obesity—there are remarkable innovations taking place, and we don’t want payment policy to inhabit innovation. But I saw a figure from Reuters that in 2021, the median cost of a novel therapy approved by the FDA [Food and Drug Administration], was $180,000, then $220,000 in 2022, and $230,000 in 2023. And when we think about balancing things, we must also not thwart innovation.