The root cause: an anti-competitive PBM model
In a free and fair market, the drug with the best outcomes data for each patient at the best price would win. Humira has been on the market for so long that its patents have expired and biosimilars have been available to 96% of the world’s population outside of the U.S. for years. Humira is not the best at anything; it is just one of many inflammatory drugs with average clinical data. As proven in clinical trials, different drugs work for different people. For instance, in rheumatoid arthritis (RA) trials, only 10% of those taking Humira achieved a great response (ACR 70 score), while 76% achieved a mediocre to no response. Fewer than 25% of patients receive a good response from the best-selling drug of all time.
Read the full article at: https://www.benefitspro.com/2023/05/04/why-biosimilars-will-fail-and-what-we-can-do-about-it/
“It’s the law unintended consequences,” Pramod John, Ph.D., chief executive officer of Vivio Health. “The ACA’s intent was not that providers now can charge whatever they wanted for service, whether a drug manufacturer or hospital. It was trying to protect a member could have a million dollar out of pocket costs in a year. This is when we started to see expansion of drug pricing because now with out-of-pockets limits, it doesn’t matter whether a drug costs $6,000 or $600,000.”
Pharmaceutical manufacturers, John said, started offering copay cards after high-deductible plans were launched. “Now a drug manufacturer can arbitrarily raise the price of a drug or remove all pricing sensitivity for the cost of the drug by paying patients’ copays and deductibles.”
Ultimately, it’s a steering mechanism, he said. “Copay cards set up economic incentives that favor the wrong behavior,” John said. “We’ve removed pricing sensitivity for patients and incentivized providers to be able to jack up the price of goods and services.”
Read the full article at: https://www.formularywatch.com/view/patients-often-lose-in-the-battle-between-pharma-and-pbmsSan Leandro, CA – VIVIO, the leading drug outcomes company, proudly announces third-party validation of specialty drug savings delivered for VIVIO customers. Validation Institute independently certified a self-funded employer with 27,000 covered lives that spent 39% less in their first year with VIVIO than they did in the previous year with a Big-3 PBM.
The analysis compared an employer’s specialty drug costs in 2021 with a traditional PBM to that same employer’s specialty drug costs in 2022 managed by VIVIO.
This chart summarizes the Per Member Per Month (“PMPM”) costs for the employer before VIVIO and the following year with VIVIO. VIVIO’s PMPM costs were 39% lower than under the prior plan.
While PBM models focus on formularies that exclude drugs and limit drug access, VIVIO takes the opposite approach of personalizing drug therapies for each patient without formulary restrictions.
“As an independent, objective third-party organization, Validation Institute provides unbiased, data-driven insights on healthcare programs. The goal is to put more purchasing power into buyers’ hands,” said Benny DiCecca, Validation Institute CEO & President. “Our team found that the VIVIO program significantly reduces specialty drug costs.”
“We are delighted to have received independent third-party validation of the VIVIO program,” said Chris Crawford, VIVIO’s Chief Growth Officer. “We have taken a different approach than the traditional PBM model, which is proven to deliver better health outcomes for the members we serve and lower costs for our employer customers.”
About VIVIO
We prioritize health outcomes by fixing the following system problems: identifying expensive drug therapies that don’t work even though they have FDA approval; not knowing if a member is responding adequately to the therapy; doctors not reading the clinical trials themselves; the arbitrary line between pharmacy and medical benefit; and, egregious supply chain waste. VIVIO uses clinical trial, patient, and financial data to drive better health outcomes while eliminating wasted spending. VIVIO Precision Care™ plugs into an employer’s current carriers and PBMs. In 2021, VIVIO customers spent 67% less on specialty drugs than the national benchmark.
About Validation Institute
Validation Institute is a professional community that advocates for organizations and approaches that deliver better health value and stronger health outcomes at lower cost. We connect, train, and certify health care purchasers, and we validate and connect providers delivering superior results. Founded in 2014, the mission of the organization has consistently been to help provide transparency to buyers of health care. To learn more about Validation Institute, visit validationinstitute.com
Media contact:
T. J. Tedesco
[email protected]
For PDF of this news release, click here.
San Leandro, CA – VIVIO, a leading drug outcomes company, announced today that Eric Channer has joined the company as Chief Financial Officer.
Eric is an experienced CFO in the health insurance and medical benefits industry. Prior to VIVIO, Eric was CFO of AmeriBen, a third-party administrator of medical insurance. He helped lead that company through significant growth, various ownership structures, and a merger with Elevance Health. Eric began his career in public accounting with KPMG. Throughout his career, he has provided cultural and ethical leadership, business acumen, and an unwavering commitment to core values. Eric is active in his community, volunteering time to various charitable organizations. A licensed CPA, Eric received his bachelor’s and master’s degrees in accounting, graduating Magna Cum Laude, from Brigham Young University’s Marriott School of Business.
“Better health outcomes matter,” said Eric. “Now, I’m part of a corporate ecosystem that uses this knowledge to ensure every patient receives a better health outcome at an affordable cost.”
“We are delighted to have Eric join our leadership team,” said Pramod John, VIVIO CEO. “His financial skills and health industry experience will greatly benefit our current and future customers, stakeholders and the specialty drug industry as a whole.”
“I have always been a values and purpose-driven individual. Business has great potential to do good in this world, and VIVIO, a public benefit corporation, is rising to that potential,” said Eric. “We will not only improve the physical health of our members and their families, but we will leave families, businesses, communities, and the world better than we found them. This is a cause worth fighting for and I’m excited to be a part of VIVIO.”
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About VIVIO: We prioritize health outcomes by fixing the following system problems: identifying expensive drug therapies that don’t work even though they have FDA approval; not knowing if a member is responding adequately to the therapy; doctors not reading the clinical trials themselves; the arbitrary line between pharmacy and medical benefit; and, egregious supply chain waste. VIVIO uses clinical trial, patient, and financial data to drive better health outcomes while eliminating wasted spend. VIVIO Precision Care™ plugs into an employer’s current carriers and PBMs. In 2021, VIVIO customers spent 67% less on specialty drugs than the national benchmark.
For more information or a higher res image, contact T.J. Tedesco at [email protected]
San Leandro, CA – VIVIO, a public benefit corporation reinventing the use of drug trial data in care delivery, announces a relationship with Mark Cuban Cost Plus Drug Company (Cost Plus Drugs) to acquire specialty drugs for less. Since Cost Plus Drugs and VIVIO are Public Benefit Corporations (PBCs), improving public health by lowering the cost of healthcare is as important as the bottom line.
America spends $500 Billion a year on prescription drugs. Less than 2% of prescriptions are written for ‘specialty’ drugs, but these account for $250 Billion, half of America’s total drug spend. Clinical trials and real-world evidence demonstrate that suboptimal drugs are being prescribed frequently. This means we pay for drugs that often don’t work because no one is asking the question, what do these drugs do? VIVIO’s team of clinicians and researchers match drug trial evidence to individual patient data, which improves outcomes, reduces side effects, and lowers member, employer, and health plan drug costs.
“The event that led to finalizing the collaboration between VIVIO and Cost Plus Drugs is as horrific as it is incredibly uplifting,” said Mark Cuban. “Last week I was contacted by a friend from Indiana University who mentioned that a mutual friend was in a dire situation. The mutual friend was quoted a price of $3,000 per month for a generic specialty drug called droxidopa. He asked if Cost Plus Drugs could find an affordable source of the medication.”
The Cost Plus Drugs team went to work immediately, says Cuban. Within a week, Cost Plus Drugs had sourced the same medication at a price of $75 for a three-month supply, less than 1% of the cost Cuban’s friend was paying. “I mentioned this in an interview with Trevor Noah on The Daily Show and this caught the attention of Pramod John, the CEO of VIVIO. As it turns out, VIVIO also has patients taking droxidopa. I am excited to say our relationship was finalized in a matter of days,” said Cuban. “Now VIVIO patients will have access to pay far less for droxidopa and many other medications when using Cost Plus Drugs. I am so looking forward to us working together to benefit patients everywhere!”
“As a Public Benefit Corporation, the interests of VIVIO, our patients, and our employer and health plan customers must be aligned. They want better outcomes and lower costs, and so do we. Unlike PBMs, we don’t have a formulary or own any pharmacies or provider services. Instead, our sole business is to use data to ensure drugs are working for each patient and are acquired at the lowest cost,” says Pramod John, VIVIO CEO. “We seek to partner with other like-minded innovators to drive meaningful change to an industry that desperately needs it but doesn’t want it. Our relationship with Cost Plus Drugs allows our customers to stop overpaying for drugs, and that’s an important part of our mission.”
“A foundational principle for Cost Plus Drugs and VIVIO is fairness and transparency,” says Alex Oshmyansky, CEO of Cost Plus Drugs. “It is never fair to pay $3K for a drug that’s available for $21 or to pay for a drug without the data supporting its use. This causes inflation, premium increases, and a bloated, inefficient $4.2 Trillion health system.”
About VIVIO Health, a Public Benefit Corporation
VIVIO Precision Care™ uses data to fix the big unsolved problem of paying for expensive drug therapies that don’t work for members while causing side effects. VIVIO helps self-insured employers and health plans ensure their members are on the right drugs while not overpaying for them. In 2021, VIVIO customers’ specialty drug spend was 65% lower than national benchmarks.
About Mark Cuban Cost Plus Drug Company, a Public Benefit Corporation
Cost Plus Drugs aims to change the way the pharmaceutical industry operates. As a public-benefit corporation, its social mission of improving public health is just as important as the bottom line. Cost Plus Drugs transparently charges a standard markup on every drug it sells. The costplusdrugs.com online pharmacy launched in January 2022 now carries nearly 1,000 prescription products, delivered by mail to thousands of happy customers every day. Cost Plus Drugs works with health plans, managed-care organizations, pharmacy benefits managers (PBMs), and self-insured employers to bring these same savings to employer-sponsored benefit plans nationwide.
For more information, contact Chris Crawford at [email protected]
The original press release can be found at: http://www.prweb.com/releases/2022/10/prweb18961234.htm
We are thrilled to announce that Lisa Zeitel, former Coalition & National Pharmacy Practice Lead for Aon, has joined our advisory board. During her tenure at Aon, she oversaw the fastest growing pharmacy purchasing coalition in the US, representing over $4.2B in drug spend.
Lisa is a nationally recognized healthcare and pharmacy benefit expert with a proven track record of building, overseeing, and advising innovative pharmacy purchasing coalitions and solutions for self-insured plan sponsors. Most recently, she was SVP, Strategic Coalition Lead for Aon’s National Pharmacy Practice. Lisa started out her career in the consulting industry at Mercer where she spent 13 years on both medical and pharmacy benefits. Selected by Business Insurance as a “Women to Watch” in the insurance, risk management, and employee benefits industries, Lisa has distinguished herself as a masterful negotiator and a passionate, highly effective, results-driven client advocate.
Our analysis indicates that Alternative Funding Programs which exclude specialty drugs from coverage and then use Patient Assistance Programs for funding are exposing employers and employees to ERISA and IRS risks and violations. More importantly it is likely a violation of fiduciary responsibility for self-funded plans. See the details of the analysis below.
VIVIO’s CEO Pramod John had an opportunity to speak with the FTC during their Listening Forum on the impacts of healthcare consolidation.
I am Pramod John, CEO of VIVIO. Today we would like to advocate for the 314M Americans who don’t work for the US healthcare system and who pay for the most inefficient healthcare system in the world.
Americans are 4% of the world’s population but spend 49% of all global healthcare dollars. Said another way, we spend as much on healthcare as 96% of the world’s population. This is in stark contrast to the America that has been the lighthouse for free markets, with the result being that we pay some of the lowest prices in the world for almost every good or service, except healthcare, where we are the worst of the worst.
This inefficiency has its root in the belief that this is a market dysfunction problem. As insiders from the industry, we disagree with the notion that healthcare has a market. Instead, we have watched the chess game unfold over the past several decades between health plans whose customers were supposed to be consumers but are providers and provider systems that are shielded from competition. The result has been the massive consolidation of health plans, PBMs and Health Systems. The repercussion has been vertical and horizontal monopolies of health plans and systems that now control the market. Of course, the nuance is that they aren’t monopolies but rather oligopolies.
I previously worked for one of these oligopolists, where the industry mantra was ‘don’t do anything to start a pricing war; it would hurt us all.’ The scale and capital of these organizations allow them to influence laws that benefit their industries and prevent competition using laws, lobbies, and ‘dumping’, which prevent any real competition or innovation. The issue isn’t any of the individual entities themselves but the business models, which lead to ‘less’ competition at scale rather than the opposite.
When the ACA required that every American have healthcare coverage without any regard for the costs of the services themselves, it effectively wrote a national one-sided market into law. For a market to function, the most important mechanism is the power to say ‘no.’ Today, we neither have a single-payer system nor a free market; instead, we have the worst system possible.
We implore the FTC, DOJ, and lawmakers to consider deeply the actual dynamics of these one-sided ‘markets’ and update our antiquated laws to reflect reality and break up the monopolies that prevent competition. Please do something on behalf of the 314M Americans who aren’t listening to this hearing but are most impacted by it.
Thank You.
As a Public Benefit Company with a mission of ensuring that every patient is on an effective therapy at a fair market cost, we believe that regulatory agencies such as the FTC and DOJ have a responsibility to break up the structural monopolies that PBMs, Provider Systems and Health plans have created. These monopolies have resulted in 4% of the world’s population, who are Americans, paying 49% of global healthcare costs.
Pramod John, CEO, and Bhargav Raman, M.D., director, clinical product, at VIVIO Health, discuss how their system can match patients to therapies based on data rather than a formulary.
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