prescription drugs

Hepatitis C, a Miracle Cure and Gilead’s Plan

Hepatitis C, a Miracle Cure and Gilead's PlanGilead aims to eradicate hepatitis C from the planet and has enlisted an entire nation as its demonstration lab.    In return, the Republic of Georgia has gotten the best possible price on Harvoni (ledipasvir-sofosbuvir), the company’s hepatitis C drug that lists at $1,150 a pill in the U.S.

The Black Sea nation wedged between Turkey and Russia does not pay a penny (or “tetri”) to Gilead as part of a five-year Hepatitis C Elimination Program launched in April with technical support from the U.S. Centers for Disease Control and Prevention (CDC).

Gilead donated an initial 5,000 courses of Sovaldi (sofosbuvir) and, this fall, began supplying Harvoni, which it began donating at a rate of 20,000 courses annually this fall upon its approval by Georgia.

The Georgian government is funding other costs associated with the program, such as screening, administration and monitoring.  Harvoni is a once-daily tablet while patients must use Sovaldi with other medications.

With just a population of five million, Georgia has the world’s third highest prevalence of HCV infection, exceeded only by Mongolia and Egypt.   As many as seven percent of the nation’s adults carry the virus, a blood infection which can destroy the liver.  Worldwide, HCV infects an estimated 130 – 150 million people and killed 700,000 in 2013.

By the end of August, the Georgians had completed a population based prevalence survey, registered 10,564 patients in the program, started treatment on 3,022 and recorded cures for 122 of 125 patients completing a 12-week regimen.  Some estimates place the total number of Georgians infected at 200,000.

Progress but Obstacles

Despite this early progress, the Georgians are facing obstacles inherent in the complexity of the disease and the variety of current therapies, including interferon, multiple anti-virals, Sovaldi and Harvoni.  These obstacles will hinder eradication there or anywhere else – as noted by “Alexandre,” a Georgian HCV patient interviewed by Georgia Today.

“I try not to worry,” said Alexandre, “My biggest concern is that our infectionists lack experience with hepatitis C management.  The disease emerged in the 80’s and despite a large number of variations in the treatment formula, it needs high professional experience.”

The virus, discovered in 1989, has six different genotypes, the prevalence of which varies from nation to nation.  Genotype 1 is most common in the United States at 75% of those infected.  In Georgia, genotype 1 drops to 43%, accompanied by genotype 2 at 20% and genotype 3 at 37%.

Disease progression by patient also differs, from spontaneous disappearance or easy treatment of the virus, to chronic hepatitis, cirrhosis, cancer and/or decompensated liver disease requiring a liver transplant.  Patients can also vary by age, comorbidities (e.g. heart disease, HIV), treatment history, risk factors and disease stage.  Hepatitis C can also be associated with heavy alcohol use, toxins, some medications, and certain medical conditions.

As a result, selecting the right treatment alternative typically requires – even in the United States — a specialist to type the virus, assess the patient, avoid harmful drug-drug interactions and monitor for potential side effects.  “Alexandre,” for example, suffered an allergic reaction from a prescribed adjunctive medication, ribavirin.  Patients must also strictly adhere to their medications or risk full recovery.

In the United States, the National Institutes of Health (NIH) is conducting a clinical trial in Washington, DC, to assess the effectiveness of treating hepatitis C with Harvoni in community clinics led by primary care physicians, nurse practitioners, and physician assistants.  Based on trials conducted by specialist teams, the Food and Drug Administration (FDA) approved Harvoni in October 2014, but only for genotype 1; approval for genotypes 4, 5 and 6 came in November 2015.

Miracle Cure for Hepatitis C

However, a solution for the specialist bottleneck is on the way — the first all oral, single tablet chronic HCV regimen for every genotype, simple to use regardless of prior treatment, disease stage or anti-viral resistance.  Potential side effects are modest, most commonly fatigue, nausea and headache.  “This is what a miracle looks like,” enthused one hepatitis C activist on Twitter.

Groundbreaking results from clinical studies of Gilead’s sofosbuvir (Sovaldi) – velpatasvir (SOF/VEL) combination recently appeared in the New England Journal of Medicine here, here and here, and in the Annals of Internal Medicine here and here.

The new drug is on approval fast tracks in both the U.S. and Europe.  The FDA has assigned SOF/VEL a Breakthrough Therapy designation as an investigational medicine that may offer major advances in treatment over existing options.  It has also set a PDUFA approval target date of June 28, 2016.  Meanwhile, the European Medicines Agency (EMA) has granted SOF/VEL Accelerated Assessment.

“This drug regimen changes the standard of care in treating patients with HCV. We can now cure almost everyone with a very simple treatment,” explained Dr. Jordan Feld, MD, MPH, lead author of the NEJM studies, to the Toronto Star.

“Knowing which treatment to use for which patient required expertise, which made it much more difficult for non-specialists to treat hepatitis C.  With the single tablet that is effective for all strains of the virus, it’s hoped that family doctors, internists and nurses will step in to treat hepatitis C,” he added.

“There are some who believe that the future is a one-size-fits-all single pill, such that a primary care doctor could prescribe it without having to be concerned about genotype, viral load, or complications,” concurred Ronald Sokol, MD, of University of Colorado School of Medicine and Children’s Hospital Colorado during a liver disease conference in November 2015.

Weighing in, too, were two key CDC leaders via a NEJM editorial:  John Ward, MD, Director of the Viral Hepatitis Program and Jonathan Mermin, MD, MPH, Director, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP).  They said sofosbuvir–velpatasvir regimen could simplify HCV management, “paving the way for simple ‘test and cure’ strategies appropriate for primary care and other settings, such as addiction-treatment programs.”

In noting that this new medicine removes significant clinical obstacles to hepatitis C eradication on a global scale, Ward and Mermin are very concerned that financial and access barriers could be thwarting:

“The availability of simple, safe, and curative regimens creates opportunities for improving the health of the millions of patients living with HCV infection. At a population level, the effect of HCV medications will be determined by affordability and equitable access to HCV testing, care, and treatment. Only through these improvements can our focus be directed to what matters most: reducing the morbidity and mortality associated with HCV infection, stopping HCV transmission, and ultimately eliminating HCV as a public health threat in the United States and worldwide.”

Pricing the Miracle Cure

How do you price a new miracle cure for hepatitis C, serving both shareholders and patients?   Gilead likely is still working the problem, deploying a process much like the one it used to price Sovaldi.  The U.S. Senate Finance Committee revealed the process in a December 2015 report, which the Wall Street Journal described as providing “perhaps the most transparent look ever into pricing decisions in the modern drug business.”

Aside revenue maximizing accusations and price gouging insinuations by Sens. Ron Wyden (D-OR) and Chuck Grassley (R-IA), Gilead actually deployed a very deliberate pricing process.  It calculated the value added by Sovaldi compared to existing treatments and balanced that with forecast of patient “starts” (volume), potential payer access restrictions and clinical obstacles like the specialist bottleneck.

Then, amidst U.S. market competition and payer resistance for 2015 sales, it discounted both Solvadi and Harvoni by an average of 46% to an estimated $643 per tablet for Sovaldi and $536 per tablet for Harvoni.

In Europe, Gilead negotiated a $536 per tablet price for Sovaldi with both Germany and France, although the deal with France includes volume incentives.  Globally, list and negotiated prices tracked a nation’s ability to pay, as measured by gross domestic product, gross national income and health expenditure per capita.

Meanwhile, Gilead has signed licensing agreements with 11 Indian generic manufacturers to produce and distribute generics for Sovaldi and Harvoni in 101 developing countries.  In addition, it has signed agreements with three companies in Egypt and Pakistan for local distribution within those countries.

In May 2015, Médecins Sans Frontières/Doctors Without Borders (MSF) reported that one of the Indian generics makers was charging $189 per 28-day-supply bottle, or $567 for a full 12-week treatment course of sofosbuvir (Sovaldi).  However, it is unhappy with Gilead’s generic licensing strategy, saying that it prohibits licensees from selling in 50 middle-income countries and excludes additional generics makers who want licenses.

Setting the Stage for Launch

Notably, Gilead has already included its breakthrough SOF/VEL combination drug in these generic licensing arrangements, anticipating approvals from the FDA, EMA and regulatory bodies elsewhere.  Alluding to SOF/VEL and its forthcoming launch, MSF notes, “People living with HCV and governments around the world have high expectations.”

However, MSF suggests governments do not have to wait for “patent and regulatory barriers” to come down, especially in middle-income countries.  To secure access to affordable treatment, MSF advises:

“Through measures taken at the domestic level, or through collective engagement at the international level, low-cost generic medicines – which cost a fraction of the high prices charged by Gilead – could be provided.”

Already, another group, Initiative for Medicines, Access & Knowledge, is challenging Gilead patents or patent applications in China, Argentina, Brazil, Russia and Ukraine.

The Republic of Georgia is among the 50 middle-income countries MSF wants included in Gilead’s voluntary licensing program – “or else.”  Rather than expand its licensing program to these countries, Gilead reveals a different strategy with its Georgian demonstration project – one of engagement with these nation’s governments coupled with financial assistance from multilateral organizations.

“We will take the Georgia data to other countries around the world to really make the case that investment can fundamentally change the disease over time,” explained Gregg Alton, Gilead’s executive vice president, corporate and medical affairs.   “Gilead cannot cure hepatitis C globally on our backs alone.”

Launching the Miracle Cure

Just another pharmaceutical product launch, SOF/VEL will not be.  Instead, look for Gilead to announce a global campaign to eradicate hepatitis C, answering the global call of patients, health systems, governments, multilateral organizations and even the Economist newspaper.

Photographs will show generics produced and ready to ship, videos will document compelling patient stories in Georgia, agreements will chart the expansion of Georgia-like demonstrations and support from multilateral organizations.  Perhaps, even MSF and Gilead leaders will stand together at the press conference.

In the U.S. and the developed world, shifting to a primary care screen and treat model, removing the specialist bottleneck, should provide an increase in patient starts justifying list and negotiated prices much lower than those of Sovaldi and Harvoni.

Watch, too, for the rollout of education campaigns to increase screening and diagnosis, and special initiatives in prisons and among substance abusers, recognizing that about half of all those with HCV have yet to be diagnosed.  Again, at the press conference, expect representatives from government, medical societies and the big pharmacy benefit managers to stand with Gilead.

Stay tuned!

Scaling the Limits of Scale: The PBM Path to Value-Based Health Care

Scaling the Limits of Scale: The PBM Path to Value-Based Health Care
Scale has its limits, as the nation’s two largest pharmacy benefit managers (PBM) are discovering.  Express Scripts and CVS Caremark each process more than a billion prescriptions a year.   That is not enough for big customers Anthem and Aetna.  Both are likely to alter dramatically or not renew long-term contracts set to end in 2019 with the PBM behemoths.

PBM Optionality for Anthem, Aetna

Anthem and Aetna say they now have “optionality” because Cigna and Humana, which they are respectively acquiring, both have PBMs.  That optionality goes well beyond the scale Aetna would enjoy as the fourth largest PBM.  It can put the pharmacy benefit, integrated within each organization, on the path to value-based health care.

Both the Humana and Cigna PBMs align well with the quality and outcomes focus of value-based health care.  Humana’s PBM primarily supports the company’s Medicare Advantage (MA) and Part D programs, with MA accountable care arrangements delivering better outcomes than traditional Medicare.

Meanwhile, Cigna has pioneered outcomes-based reimbursement arrangements with pharmaceutical manufacturers.  Previously overseeing Cigna’s PBM was none other than Aetna CEO Mark Bertolini; Cigna CEO David Cordani will serve as chief operating officer of the new Anthem.

In their sights is UnitedHealth Group (UHG), which brought its PBM business inside from Medco at the start of 2013, trigging Express Scripts’ anticipatory acquisition of Medco in 2012.    UHG says its OptumRx PBM focuses “on connecting total condition spend and pharmacy’s impact across benefits,” a process it calls “synchronization.”

More explicitly than Anthem, Aetna has said it will integrate Humana’s PBM, along with its “growing health care services business,” even characterizing it as an “Optum-like business.”

Value beyond Scale

UHG’s Catamaran acquisition earlier this year, while adding scale, also significantly included Catamaran’s RxClaim processing platform.  OptumRx plans to integrate the adjudication platform with its medical and pharmacy claims synchronization.  UHG promises to create value “beyond the scale … resulting from integration,” by linking “demographic, lab, pharmaceutical, behavioral and medical treatment data” to encourage healthy decisions and improve compliance with pharmaceutical use and care protocols.”

In fact, the very tools used to leverage scale to get lower prices, such as formulary exclusions, can potentially work against reducing total costs.  In securing a substantial discount from AbbVie for Viekira Pak, Express Scripts excluded Gilead’s Harvoni from its 2015 formulary.  Viekira Pak is a four pill a day regimen to Harvoni’s adherence-friendly one pill for curing hepatitis C.

Not surprisingly, given their focus on overall costs, Aetna, Anthem, UHG and Cigna all included Harvoni on their formularies and do not publish exclusion lists like Express Scripts and CVS Caremark.  Instead, they typically establish clinically based prior authorization criteria.

For the latest high-cost drugs to hit the market, Express Scripts is following the health plans on their value path.  Instead of excluding one of two new anti-cholesterol drugs, known as PCSK9 inhibitors and list priced at $14,000 per year, it announced coverage for both this week.

As the health plans did with Harvoni, Express Scripts will implement rigorous prior authorization procedures.  The company says it negotiated good pricing with Amgen for Repatha and with Sanofi and Regeneron Pharmaceuticals for Praluent, enabling it to cover both drugs.  Perhaps it also heard from customers unhappy with price-driven drug exclusions.

Wanting More, Customers Become Competitors

Clearly, some very big customers – Aetna, Anthem and UHG – want something more than scale from traditional PBMs like Express Scripts and CVS Caremark.  Beyond scale, they want a pharmacy benefit that contributes to reducing total costs through better outcomes, consistent with achieving overall value-based payment goals.

Building PBM paths to value-based health care for themselves, Anthem, Aetna and UHG will also sell against volume-based models like those of Express Scripts and CVS Caremark, and against health plans that fail to integrate pharmacy and medical claims for actionable intelligence.

Employers and the Limits of Scale

Their strategy blueprint could easily have come from the Harvard Business Review article “The Limits of Scale.”  Hanna Halaburda and Felix Oberholzer-Gee argue that, when rapidly scaling companies neglect to take into account differences among their customers, performance declines.  On that premise, they suggest how challengers and incumbents can take advantage of customer differences.

Among PBM customers with differences are employers, which provide health coverage for 147 million Americans.   The National Business Coalition on Health is uneasy with the growing use of exclusionary formularies.  It advises members to “base selection criteria for formularies on clinical outcomes to ensure that pharmaceutical costs do not decrease at the expense of rising medical costs.”

Employers are becoming more actively engaged in managing the pharmacy benefit, even developing their own formularies and negotiating directly with pharmacy retailers.  Caterpillar’s Daren Hinderman told an NBCH panel last year, “I don’t want to have a conversation [with PBMs] on rebates; I want to have a conversation on how I can keep my employees more compliant with medications they need to stay healthy. We decide what’s best for our employees. It’s a transparent process.”

NBCH also urges members to “verify that pharmacy and medical benefits are aligned, and link data between the two in order to evaluate cost and outcomes across both types of benefits and the entire health-care spectrum, not just through the lens of pharmacy.”  As Dr. Mark Fendrick of the University of Michigan Center for Value-Based Insurance Design told the NBCH panel, “I’d prefer to spend more on statins than on stents.”

Obstacles on PBM Value Path

Mapping the PBM path to value-based health care is one thing, building it is another.  Aetna and Anthem still must face a gauntlet of government and legal reviews before they can complete their acquisitions and commence integrating the Humana and Cigna PBMs.

OptumRx must complete its integration of Catamaran, which in turn is still integrating the data platforms of its acquisitions.  Furthermore, OptumRx and Catamaran both use different versions of the RxClaim platform and, for Catamaran, medical claims synchronization remains down the road (or path).

Meanwhile, the Catamaran acquisition has roiled a PBM industry where many participants use Catamaran’s RxClaim platform – including Cigna!  They were content to compete with Catamaran, despite using its technology.  However, will they be similarly comfortable with OptumRx and UHG in the technology driver’s seat?

Much like UHG’s acquisition of Catamaran and its technology, Rite-Aid did the same when it acquired EnvisionRx.  The PBM had previously acquired Laker Software, also a claims platform supplier for many PBMs.  Again, the comfort question arises, in this case over Envision and Rite Aid as the drug retailer pursues its path to value-based health care via innovative alliances with health care providers.

Making the Laker and RxClaim platforms particularly valuable has been the PBM industry’s reliance on a hodge podge of decades-old, antiquated platform technologies.  With each acquisition, scaling PBMs have patched together instead of invested in their platforms to maximize short-term synergies, at the cost of limited flexibility and lower efficiency.

PBMs Miss Technology Revolutions

Meanwhile, multiple revolutions have coursed through the systems development world since the PBM industry acquired its mainframes and data centers in the late 1980’ – early 1990’s.   When relational databases followed soon thereafter, PBMs adopted them for after-the-fact data analysis, but not broadly for real time use with claims processing platforms, which now are antiquated and fragmented.

More recently, graphical user interfaces have greatly streamlined the programming of business intelligence applications.  It is now easier for more people, more efficiently to translate their expertise into innovative systems.  No longer must visionaries exclusively funnel their solutions through highly specialized programmers and coders.  Now, the visionaries’ can become coders, their hands on the programming controls, unleashing new applications across the entire economy, including the PBM industry.

PBM Platform for Value-Based Health Care

One such visionary has developed a PBM solution for value-based health care.  His name is Ravi Ika.  “The solution is holistic, unlike that of any other existing PBM.  It reduces overall pharmacy cost, converts specialty from ‘buy & bill’ to ‘authorize and manage,’ and lowers avoidable drug-impacted medical costs,” explains Ika.

Before turning his attention to the PBM industry, he created a comprehensive, integrated payer platform now provided by ikaSystems, which he founded to transform the payer operating model.  Spanning all payer departments and business lines, it decreased administrative costs for health insurers by as much as 50% and reduced avoidable medical costs.

In 2013, Ika launched RxAdvance, a full service PBM, which similarly operates on an integrated, end-to-end platform – one designed specifically for value-based health care.   Combining pharmacy, medical, and lab data, the platform – called PBM Collaborative Cloud– enables real-time engagement.  This engagement occurs with physicians at the point of care, pharmacists at the point of sale, and patients via mobile cloud.  It also engages payers clinical and pharmacy staff through their workflows.

Better decisions by these stakeholders – driven by platform-generated, actionable intelligence – can reduce avoidable drug-impacted medical costs, optimize utilization, facilitate better specialty drug management, and decrease overall pharmacy costs.

PBM Processes Reimagined

“We started with a clean slate,” observes Ika, who says he and his team reimagined PBM processes to streamline workflow before building the platform.  Redefining the human role, they automated as much as possible while, on the other hand, increasing opportunities for engagement, what-if modeling, and informed decision-making.  The platform also enables market and regulatory changes configurable by the business user, as well as system-driven compliance management.

Ika built the platform from the ground up using a unified data model.  In information technology parlance, that means the platform’s standards are universal enough to encompass a large scope of data and types of data with high scalability.

In PBM language, the platform includes everything from pharmacy claim adjudication, formulary management, benefit design, enterprise reporting and analytics, to pharmacy network and rebate contracting, medication adherence and therapy management, specialty management, transparency, compliance, and adverse drug event management.

From Existing to Ideal Formularies

For example, the platform includes algorithm-driven artificial intelligence to manipulate, with plan sponsor engagement, the complex and interdependent variables associated with formulary management.  Incorporating habitual member and prescriber utilization patterns, in addition to other data, it derives an ideal formulary with optimal financial and clinical outcomes.  The system then maps a transition plan from an existing formulary.  The platform also accommodates an unlimited number of formularies and supports real time dynamic modeling and changes coupled with full transparency.

Better Medication Therapy, Adherence Outcomes

For medication therapy management (MTM), the platform taps patient medical claims and disease conditions, against which the system overlays a prescription listing for easy use by prescribers.  In addition, each new prescription triggers a dynamic analysis to determine patient eligibility for a comprehensive medication review (CMR), which the system prepopulates for efficient prescriber use.

After the CMR, RxAdvance advisors rely on system alerts to intervene with patients to ensure medication adherence.  For high-risk patients, RxAdvance will install an electronic, patent-pending pill station at their residences and resupply it with disposable pre-filled pill trays.

Integrated with and wirelessly connected to the company’s platform, the device assists with monitoring adherence and vital signs.   The company says the device has improved adherence to more than 93%, including patients with multiple chronic conditions who are taking an average of 15 medications a day.

The Centers for Medicaid and Medicare Services (CMS) recently underscored the PBM need for physician-led, point-of-care MTM capability when it announced a new Medicare Part D MTM model.  Currently, highly fragmented PBM MTM relies on pharmacists “chasing” patients without closing the loop with prescribers, thus failing to secure meaningful health outcomes, according to Ika.

Ika points to the RxAdvance specialty management program as another example of his platform’s capabilities.  As it does for MTM, the platform integrates prescriptions, medical claims and disease conditions to create an action plan for all stakeholders.  Case managers use a dashboard to prioritize their outreach to patients, prescribers and pharmacists.  Because the platform integrates medical, pharmacy and lab information, it helps facilitate appropriate utilization.

Risk Sharing

One of the hallmarks of an organization configured for value-based health care is its ability to share risk.  The RxAdvance unified data model platform enables it to share risk for both pharmacy and avoidable drug-impacted medical costs.  For pharmacy, it is prepared to assume both up and down side risk based on its cost management performance against a risk cap set below a national benchmark projected increase.

The company can also compute a baseline trend for avoidable drug-impacted medical costs using prior years’ medical claims data.  RxAdvance and its client then set a target and, if the PBM lowers actual avoidable drug-impacted medical costs, it will share in the savings.  According to Ika, this sort of risk sharing is unique in the PBM market.

Ika reports that RxAdvance is currently implementing full PBM services for three clients, replacing national PBMs.  “The Collaborative PBM Cloud platform is making for a very smooth launch,” he notes.

RxAdvance has gotten a head start along the PBM path to value-based health care, scaling the limits of scale.

High Drug Prices: What Would Donald Trump Say?

Trump_Debate

In a new poll released yesterday, the Kaiser Family Foundation reported that large majorities of Americans, regardless of political party, think drug prices are unreasonably high, drug companies put profits before patients, and government should limit the cost of high priced drugs and negotiate lower prices for Medicare.

However, the same poll found that 76% of Republicans preferred market competition over government regulation to lower drug prices.  In addition, while 74% of Republicans say the government should directly negotiate Medicare drug prices, a smaller number – 56% — believe it can be effective.

Perhaps this explains why Republican candidates for President have not addressed high drug prices, preferring instead to focus on Obamacare repeal, as reported by Politico.  Neither Scott Walker nor Marco Rubio have included drug prices in their Obamacare replacement proposals.

Will Donald Trump take on high drug prices?  If he does, what would he say?  Whatever he says about an issue quickly frames how other Republican candidates and the news media speak about it.  Such is Trump’s dominance of the daily news cycle.   That alone makes the question relevant and the answer useful.

He is also more in tune with the Republican base than the party’s establishment may want to admit, as   political commentator Ezra Klein observed earlier this week.  Trump is the only Republican candidate who opposes cuts in Medicare, Social Security and Medicaid, a long-held position he directly links to making American strong again.

Interviewed on Larry King in 1999, he said, “What’s the purpose of a country if you’re not going to have defense and healthcare.  If you can’t take care of your sick in the country, forget it, it’s all over. I mean, it’s no good.”   He told the Iowa Freedom Summit earlier this year, “I want to make the country rich so that Social Security can be afforded, and Medicare and Medicaid.”

Recently, on Meet the Press, he said, “I want people to be taken care of from a health-care standpoint. But to do that, we have to be strong. I want to save Social Security without cuts. I want a strong country. And to me, conservative means a strong country with very little debt.”

In fact, Trump comes across as a Robin Hood, putting himself on the side of American citizens, taking money from wealthy countries he says rightfully belongs to us, fighting government corruption and stupidity, and expelling illegal aliens (to use his terminology).   He is also a deal maker, exploiting leverage or creating advantage to get what he wants.

What, then, would Donald Trump say about high drug prices?  To answer that question, here is an imagined Meet the Press conversation between host Chuck Todd (imagined) and Donald Trump (imagined).   It suggests Donald Trump could easily take high cost drugs to a place neither the other Republican candidates nor the drug industry want to go.

 

Chuck Todd (Imagined):

Mr. Trump, in a new poll, 70% of Republicans want the government to limit how much pharmaceutical companies can charge for high-cost cancer drugs.  What would you do about the high cost of prescription drugs?

Donald Trump (Imagined):
Repeal Obamacare and replace it with something terrific.  It’s a disaster.  It’s virtually useless and big lie.  Deductibles are through the roof and costs are going up.

 

Chuck Todd (Imagined):

How would repealing Obamacare lower drug costs?  They’re growing faster than other health costs – mainly because of the new specialty drugs – but they still only account for 10% of all health spending.

Donald Trump (Imagined):

Chuck, the drug company lobbyists did a fantastic job when Congress passed Obamacare.  They out-negotiated the President and got a great deal.  They supported Obamacare and agreed to help pay for it.  In return, they got more customers and higher prices.   When I repeal and replace Obamacare, the pharma companies will have to negotiate with me.

 

Chuck Todd (Imagined):

Does that mean you support letting the government directly negotiate with drug companies over the prices it pays for Medicare drugs?

Donald Trump (Imagined):

Medicare is the largest single buyer of prescription drugs.  In business, a best customer gets the best deal.  When I buy televisions for my hotels, which I sadly can’t get in the US but that’s another issue, I use that leverage for a great price.  Yes I’d negotiate better prices with the drug companies.  But, it’d be different, like a business, not as price controls or more regulations in disguise.   You’ll be very pleased, very pleased with how I do it.

 

Chuck Todd (Imagined):

But, what about the cost of drugs not covered by Medicare….these new cancer drugs that cost thousands of dollars.  In fact, the doctors who treat cancer are campaigning for lower prices.

Donald Trump (Imagined):

Chuck, I’ve got a deal where everyone wins.  I love the drug companies.  They’ve made great discoveries and cured many people.  I want the drug companies to create jobs in the US, making new drugs.  That takes money.  They hold almost a half-trillion dollars outside the United States because the taxes on bringing it home are too high.   Bring those dollars home, use them for jobs, discover new cures, keep prices under control and I’ll lower the taxes.

 

Chuck Todd (Imagined): 

Republicans also think Americans should be able to buy prescription drugs imported from Canada, and by a wider margin than Democrats:  75% Republicans vs. 69% Democrats.  What do you think of that?

Donald Trump (Imagined):

The problem is much bigger.  What our pharmaceutical industry accomplishes is tremendous.  It benefits the entire world but prices are highest in the United States.   Per person, we spend twice as much as other wealthy nations.    It’s time other nations paid their fair share.  As you know, rich nations like Saudi Arabia must pay us back for what the Defense Department spends on protecting them.  Canada, the European Union and other wealthy nations should help pay for our National Institutes of Health.  The American taxpayer funds 85% of basic research.  We have to stop subsidizing their health care.

 

Chuck Todd (Imagined)

The drug industry says that it needs to charge high prices because it takes so long to bring a drug to market.  Would you make any changes at the FDA?

Donald Trump (Imagined)

The FDA needs to do a better job on safety, especially after a drug is on the market.  Take vaccines, I don’t think kids should get them all at once.  Spread them out.  It doesn’t hurt anybody other than probably the pharmaceutical companies because they probably make more money putting it into one shot.    I want more approvals and more competition.  That will bring prices down.

 

Chuck Todd (Imagined):

Speaking of health care.  Earlier, you said you would repeal and replace Obamacare.  How would you replace Obamacare?

Donald Trump (Imagined):

I believe in universal healthcare. I believe in whatever it takes to make people well and better.  What’s the purpose of a country if you’re not going to have defense and healthcare?  We can have something far better for the people, and far less expensive, both for the people and for the country.  And believe me there are plans that are so much better for everybody.  And everybody can be covered.  I’m not saying leave 50-percent of the people out.

 

Chuck Todd (Imagined):

How would you pay for it?

Donald Trump (Imagined)

Get tough with the big players like China and OPEC that are ripping us off so we can recapture hundreds of billions of dollars to pay our bills, take care of our people, and get us on a path toward serious debt reduction. We must take care of our own people—we must make our country strong and rich again so that Social Security, Medicare, and Medicaid will no longer be thought of as a problem. We must save these programs through strength, power, and wealth.

 

Chuck Todd (Imagined):

During the debate, you seemed to speak favorably about single payer systems in Scotland and elsewhere.  Do you favor a single payer system in the United States?

Donald Trump (Imagined):

No.   What we need in the United States is free market plan that provides consumer choice, keeps plans portable and affordable and returns authority to the states. We also must break the insurance company monopolies and allow individuals to purchase health insurance across state lines.