Congressional Budget Office Releases: Alternative Approaches to Reducing Prescription Drug Prices

As healthcare costs soar, the Congressional Budget Office (CBO) has recently shed light on a hot political issue: the perceived high cost of prescription drugs in the United States. Their latest report, published in October 2024, meticulously analyzes various policy measures aimed at curbing these costs.

The Core Problem

Prescription drug pricing remains a critical political issue, impacting the financial well-being of millions. The CBO’s report underscores a complex interplay of market exclusivities, competition, and regulatory measures that set the stage for current drug prices. As detailed, these factors, including exclusive sales rights and insurance coverage, significantly insulate consumers from direct costs, affecting drug price sensitivity and market dynamics.

Policy Approaches and Their Implications

The report discusses seven main policy strategies that according to the Congressional Budget Office could potentially lead to lower prescription drug prices. These include setting maximum allowed prices based on international benchmarks, expanding Medicare drug price negotiation capabilities, and enforcing inflation rebates in the commercial sector.   The CBO admitted that most of these recommendations would reduce drug prices by less than 1% point with international reference pricing potentially reducing prices by up to 5%.  We will go into detail on each of the seven proposed strategies.

1. Setting Maximum Allowed Prices Based on International Prices

Mechanism: This approach proposes setting a price ceiling for drugs in the U.S. based on the average prices in certain reference countries. Impact: Expected to result in substantial price reductions by aligning U.S. drug prices with lower international levels. The strategy targets single-source brand-name drugs, using a weighted average based on GDP per capita of the reference countries. This strategy is expected to result in a large reduction in drug prices, potentially reducing prices by more than 5%. The significant reduction comes from setting price caps based on the lower prices available in foreign markets.  Challenges: Potential pushback from pharmaceutical companies, which might delay launches in reference countries or exit markets to avoid setting lower price benchmarks.

2. Expanding the Medicare Drug Price Negotiation Program

Mechanism: Currently, Medicare is limited in its ability to negotiate drug prices. This proposal would expand the scope, allowing Medicare more freedom to negotiate prices for a broader range of drugs. Impact: Anticipated to yield moderate price reductions by leveraging Medicare’s purchasing power according to CBO estimates:

• • Increasing the number of drugs whose prices get negotiated each year could lead to a very small (0.1% to 1%) or small (1% to 3%) reduction.
  • Making negotiated prices available to all commercial purchasers could result in a small reduction, typically in the range of 1% to 3%.

Challenges: Could lead to pharmaceutical companies setting higher initial prices or reducing discounts to offset the impact of broader negotiations.

3. Requiring Manufacturers to Pay Inflation Rebates for Commercial Sales

Mechanism: This strategy would extend the existing requirement for inflation rebates in Medicare Part D to the commercial market, ensuring that drug price increases do not exceed inflation. Impact: Expected to lead to modest price reductions by directly linking price increases to inflation rates. This approach would likely result in a very small reduction in prices, between 0.1% to 1%. While it aims to introduce more competition, the actual impact on overall market prices might be limited. Challenges: Implementation complexity and potential unintended consequences like companies increasing initial launch prices.

4. Allowing Commercial Importation of Prescription Drugs

Mechanism: Facilitates the importation of approved drugs from international markets where they may be cheaper. Impact: This approach would likely result in a very small reduction in prices, between 0.1% to 1%. While it aims to introduce more competition, the actual impact on overall market prices might be limited.

Challenges: Safety and regulatory concerns about the quality and tracking of imported drugs.

5. Eliminating or Limiting Direct-to-Consumer Advertising

Mechanism: This strategy would ban or severely limit DTC advertising of prescription drugs. Impact: Could reduce consumer demand for newer, more expensive medications, leading to lower drug prices. Eliminating DTC is anticipated to cause a very small reduction in prices, around 0.1% to 1%. The direct effect on drug prices might be minimal, but it could potentially reduce the demand for more expensive, heavily advertised drugs. Challenges: May impact patient awareness of new treatment options and could face significant resistance from both pharmaceutical companies and media organizations that benefit from advertising revenue.

6. Facilitating Earlier Market Entry for Generic and Biosimilar Drugs

Mechanism: Proposes regulatory or legislative changes to make it easier for generic and biosimilar drugs to enter the market sooner after the patent expiration of brand-name drugs. Impact:  Expected to result in a very small immediate reduction in prices, approximately 0.1% to 1%. Accelerating the availability of generics and biosimilars could help decrease prices over time as competition increases. Challenges: Could potentially decrease the profitability of new drugs, affecting pharmaceutical innovation and investment.

7. Increasing Transparency in Brand-Name Drug Prices

Mechanism: This strategy would require more detailed reporting and public disclosure of drug pricing structures and actual transaction prices. Impact: This strategy might lead to no change or a slight increase in prices. Transparency alone does not necessarily reduce prices but could foster a more competitive pricing environment indirectly. Challenges: Pharmaceutical companies may resist disclosure of sensitive pricing information, and increased transparency alone may not lead to price reductions without other supportive measures.

Discussion

Overall, this report requested by several progressive Democratic senators including Bernie Sanders, D (VT) goes into detail on the complexity of drug pricing and potential alternatives to the current system of drug pricing or expanding the price negotiations.  All their recommendations have serious consequences for innovation and should be considered with an eye on what can be done without impacting new product development.  One area obviously missing, is that all these recommendations are focused on the manufacturer, yet around 50% of drug spend is going to pharmacy benefit managers and others in the system without adding them to the discussion, we will be forever spinning our wheels as with reduced prices they may jump in and take more of the pie to keep their profitability the same or growing.