Share of Insulin Revenues Going to Middlemen Pharmacy Benefit Managers (PBMs) Increased by 155%

(p. B12) Pharmacy-benefit managers, or PBMs, have captured a growing slice of America’s world-leading drug spending during the past decade. The spotlight could soon shift to them.

. . .

While the three largest manufacturers of insulin—Eli Lilly, Novo Nordisk and Sanofi—charge more for their products in the U.S. than they do elsewhere, their take of overall spending has been decreasing in recent years as the relative power of middlemen has grown. PBMs have steadily gained negotiating clout by consolidating and merging with large insurance companies. The three largest PBMs are owned by CVS Health Corp. (which owns insurer Aetna), UnitedHealth Group Inc. and Cigna Corp.

. . .

. . . increases in recent years have mostly been passed on to PBMs in the form of heavy discounts that are hidden from public view.

A recent study by University of Southern California scholars showed that, between 2014 and 2018, the share of a hypothetical $100 insulin expenditure accruing to manufacturers decreased by 33%. During that same period, total U.S. spending on insulin hasn’t budged, but the share of insulin expenditures retained by PBMs has increased by 155%.

. . .

“What’s happening in this market is that the middlemen are making more and more money,” said University of Southern California professor Neeraj Sood, one of the authors of the study who has previously done consulting work for drug companies.

Yet the drug-pricing provisions in the recently passed Inflation Reduction Act singularly focused on what manufacturers charge while ignoring other players that take a slice of profits farther down the chain.

For the full commentary, see:

David Wainer. “HEARD ON THE STREET; Sanders, Musk Miss the Mark on Insulin.” The Wall Street Journal (Tuesday, November 22, 2022): B12.

(Note: ellipses added.)

(Note: the online version of the commentary has the date November 21, 2022, and has the title “HEARD ON THE STREET; Elon Musk, Bernie Sanders and Others Miss the Mark Over Pricey Insulin.”)

The academic study co-authored by Sood, and mentioned above, is:

Van Nuys, Karen, Rocio Ribero, Martha Ryan, and Neeraj Sood. “Estimation of the Share of Net Expenditures on Insulin Captured by Us Manufacturers, Wholesalers, Pharmacy Benefit Managers, Pharmacies, and Health Plans from 2014 to 2018.” JAMA Health Forum 2, no. 11 (2021), doi:10.1001/jamahealthforum.2021.3409.

Pharmacy Benefit Managers (PBMs) Create Incentives to Reduce Hiring and Pay of Pharmacists

(p. A1) If any group of workers might have expected their pay to rise last year, it would arguably have been pharmacists. With many drugstores dispensing coronavirus tests and vaccines while filling hundreds of prescriptions each day, working as a pharmacist became a sleep-deprived, lunch-skipping frenzy — one in which ornery customers did not hesitate to vent their frustrations over the inevitable backups and bottlenecks.

“I was stressed all day long about giving immunizations,” said Amanda Poole, who left her job as a pharmacist at a CVS in Tuscaloosa, Ala., in June. “I’d look at patients and say to them, ‘I’d love to fill your prescriptions today, but there’s no way I can.’”

Yet pay for pharmacists, who typically spend six or seven years after high school working toward their professional degree, fell nearly 5 percent last year after adjusting for inflation. Dr. Poole said her pay, about $65 per hour, did not increase in more than four years — first at an independent pharmacy, then at CVS.

For many Americans, one of the pandemic’s few bright spots has been wage growth, with pay rising rapidly for those near the bottom and those at the top. But a broad swath of workers in between has lagged behind.

. . .

(p. A16) Pharmacies also faced external challenges. To hold down the cost of prescription drugs, insurance companies and employers rely on so-called pharmacy benefit managers to negotiate discounts with drugmakers and pharmacies. Consolidation among benefit managers gave them more leverage over pharmacies to drive prices lower. (CVS merged with a large benefits manager in 2007.)

Big drugstore chains often responded by trying to rein in labor costs, according to William Doucette, a professor of pharmacy practice at the University of Iowa. Several pharmacists who worked at Walgreens and CVS said the formulas their companies used to allocate labor resulted in low levels of staffing that were extremely difficult to increase.

According to documents provided by a former CVS pharmacist, managers are motivated by bonuses to stay within these aggressive targets.

. . .

In most cases, an industry without enough workers to meet customer demand would simply hire more, or at least raise wages to attract them.

Yet, according to the Bureau of Labor Statistics, neither of those things happened last year. The number of pharmacists employed in the United States dropped about 1 percent from 2020 to 2021. On balance, employers did not raise wages — in fact, median pay fell slightly, even without adjusting for inflation.

. . .

Several pharmacists said they were especially concerned that understaffing had put patients at risk, given the potentially deadly consequences of mix-ups. “It was so mentally taxing,” said Dr. Poole, the Tuscaloosa pharmacist. “Every day, I was like: I hope I don’t kill anyone.”

. . .

Asked about safety and staffing, CVS and Walgreens said they had made changes, like automating routine tasks, to help pharmacists focus on the most important aspects of their jobs.

Many pharmacists contacted for this article quit rather than face this persistent dread, often taking lower-paying positions.

Still, none had regrets about the decision to leave. “I was 4,000 pounds lighter the moment I sent my resignation email in,” said Dr. Wommack, who left the company in May 2021 and now works at a small community hospital.

As for the medication she had taken for depression and anxiety while at Walgreens, she said, “Shortly after I stopped working there, I stopped taking those pills.”

For the full story, see:

Noam Scheiber. “Why Working At Pharmacies Lost Its Luster.” The New York Times (Tuesday, September 13, 2022): A1 & A16.

(Note: ellipses added.)

(Note: the online version of the story has the same date as the print version, and has the title “How Pharmacy Work Stopped Being So Great.”)

Amazon Warehouse Jobs Give “Economic Boost” to English Town

(p. B4) DARLINGTON, England—Many retailers in this old market town have long held Amazon.com Inc. partially to blame for the closures of a raft of local shops in recent years.

Then, Amazon opened a warehouse here.

The facility, which opened in early 2020, employs 1,300 full-time staff, making it one of the town’s biggest employers. It hired 500 additional seasonal workers during the end-of-year holidays. Wages start at £10 (equivalent to $13.25) an hour, above the legal minimum, and benefits include private healthcare and an £8,000 education allowance available in installments over four years.

The new jobs have all delivered an economic boost for the Northern England town of 100,000, while sparking a reassessment of the U.S. e-commerce giant. Nicola Reading, a gift-shop owner, still blames Amazon for the demise of the local retail scene but now sees an upside, too.

“It feels like Amazon employs half the population of Darlington now,” she said.

Already America’s second-biggest employer, after Walmart Inc., Amazon has been advancing in Europe and the U.K., investing €78 billion ($89 billion) since 2010 in a continentwide expansion that has significantly accelerated over the past few years. Amazon employs over 55,000 full-time U.K. staff.

. . .

Local officials in Darlington have applauded Amazon’s arrival, which they say has benefited the town, chiefly by creating jobs. Amazon’s presence is also encouraging young university graduates to stay in the town and attracting other companies, said Mark Ladyman, the Darlington Borough Council’s assistant director for economic growth.

For the full story, see:

Trefor Moss. “The Small Town That Amazon Upended, Then Saved.” The Wall Street Journal (Saturday, January 22, 2022): B4.

(Note: ellipsis added.)

(Note: the online version of the story was updated Jan. 21, 2022, and has the same title as the print version.)

A Firm Does Not Need to Be a Platform to Matter

(p. 17) Over the past two decades, the world’s hyper-ambitious entrepreneurs — is there now any other kind? — have largely pursued a pair of goals in tandem. First: Become a platform. Second: Take over the world. The former is supposed to lead to the latter, as it seemingly has for the five companies conglomerated under the intimidating acronym FAANG. Facebook, Apple, Amazon, Netflix and Google have taken such a bloodsucking bite (get it?) out of the world economy that in the past half decade alone they have more than tripled in value — at a rate three times faster than the growth of the entire S&P 500 — and are now worth north of $7 trillion. The appeal of building a platform is clear.

. . .

The word “platform” has been deployed so many times in so many ways that it has lost almost all meaning, a fact that Jonathan Knee, who teaches at Columbia University’s business school, tries to spell out in his new book, “The Platform Delusion.”

. . .

Knee’s book is filled with business school case studies that might be a bit in the weeds for general readers. (One of the successes he identifies is a company that makes software for a very specific financial accounting function.) But for aspiring entrepreneurs these stories offer a primer on the delusion Knee has identified, and show how to avoid the two primary misjudgments that cause it. The first is a belief that platforms emerged with the dawn of the internet. In fact, they’ve been around for decades.

. . .

But the crux of Knee’s argument is that “beyond their size and success” — no small feat — there is little the big platforms have in common.

. . .

Knee grants that the breadth and scope of the giant tech platforms is “awe-inspiring,” but he thinks our collective fear of them is overblown. (. . . ) The platforms have weaknesses just like any business, he argues, and the succubi themselves push the myth of their own invincibility in order to dissuade any potential competition.

But what the myth has mostly done is tempt young entrepreneurs to try to match them.

. . .

Knee believes that investors, and many of his students, are fooling themselves into thinking that building a globe-spanning platform is a viable goal. Platforms are successful not because they are platforms, but because they exploit the same kinds of advantages that successful businesses have enjoyed for decades. It’s a boring realization, but one that Knee hopes will save his students not only from pursuing bad ideas, but from ruining their lives. The platform siren song, he writes, “fatally impedes the ability of many to clearly consider what they might actually enjoy.” Not everyone needs to start a company to be happy. And not every company needs to take over the world.

For the full review, see:

Reeves Wiedeman. “Nosedive.” The New York Times Book Review (Sunday, September 26, 2021): 17.

(Note: ellipses added.)

(Note: the online version of the review has the date Sept. 15, 2021, and has the title “Why Does Every Company Now Want to Be a Platform?”)

The book under review is:

Knee, Jonathan A. The Platform Delusion: Who Wins and Who Loses in the Age of Tech Titans. New York: Portfolio, 2021.

Business Formations During Pandemic Are “Off the Charts”

Source: Haltiwanger as reprinted in WSJ article cited below.
Source: Haltiwanger as reprinted in WSJ article cited below.

(p. A4) “Sixty or more years ago, most of us, including me, were altogether too willing to treat the economy as close to fully competitive. I now think that was a mistake,” Nobel Prize-winning economist Robert Solow said in a recent interview. “The economy has grown less competitive and the elements of monopoly power are probably very important for the distribution of income between work and wealth and ultimately across individuals.”

Douglas Holtz-Eakin, president of the American Action Forum, a conservative research group, said he is skeptical of the notion that corporate power has hurt consumers. He and other Republicans say the rise of big companies such as Walmart, Home Depot and Amazon has benefited U.S. consumers by helping to push down prices.

“I take all of this talk with a healthy dose of show me,” Mr. Holtz-Eakin said. While Republicans could likely get behind some of Mr. Biden’s proposals—such as pushing back against firms forcing workers to sign noncompete clauses or states imposing what some workers say are unnecessary licensing requirements on workers—other ideas may go too far.

Some research has found less cause for concern around business consolidation. “There are reasons to be cautious about concluding that market concentration has risen or is a meaningful problem for market competition and consumer welfare,” Nancy Rose, a professor in the economics department of the Massachusetts Institute of Technology, concluded in a 2019 examination of research on the issue, citing measurement challenges among reasons for skepticism.

. . .

With the rise of a few big companies, jobs also have become concentrated there. John Haltiwanger, a University of Maryland professor, finds that the share of U.S. jobs at young, small firms declined to 16% in 2018 from 26% in 1987. During the same period, the share of jobs in older, larger firms rose from 41% to more than half.

Mr. Haltiwanger’s research shows that the U.S. economy became less dynamic during this period, with fewer new jobs created by startup firms, less job-hopping by workers seeking out new opportunities and slower worker productivity growth.

. . .

Mr. Haltiwanger said the competition dynamics might now be changing due to the coronavirus pandemic. Tracking business identification data from the Internal Revenue Service, he spotted a surge in business formations in the second half of 2020, a trend that persisted into 2021.

“It is off the charts,” he said. “I think we discovered during the pandemic that our technological infrastructure is just phenomenal. We can do almost anything we want from anywhere. That leads to lots of market opportunities. I think there is going to be a surge of dynamism. The question is will it be transitory, or true innovation?”

For the full story, see:

Jon Hilsenrath. “Economic Competition Scrutinized.” The Wall Street Journal (Monday, July 12, 2021): A4.

(Note: ellipses added.)

(Note: the online version of the story has the date July 11, 2021, and has the title “Biden Stakes Out Position in Debate Over Power of Big Companies.”)

Lack of Competition Allows Carlsbad Medical Center to Sue Thousands of Patients

(p. D1) An examination of court records by The New York Times found almost 3,000 lawsuits filed by Carlsbad Medical Center against patients over medical debt since 2015, more than 500 of them through August of this year alone. Few hospitals sue so many patients so often.

. . .

Carlsbad Medical Center is not the only hospital to have filed reams of lawsuits over unpaid bills. In Memphis, Methodist Le Bonheur Healthcare, a nonprofit hospital, filed 8,300 lawsuits from 2014 through 2018, including some against its own em-(p. D6)ployees, according to an investigation by the journalism nonprofit groups ProPublica and MLK50.

. . .

People across the country are coping with soaring medical costs, opaque pricing and surprise bills, but these issues are felt acutely in one-hospital towns like Carlsbad, where residents have few options for care — and must pay whatever prices the hospital sets.

“Hospitals that have little competition can negotiate higher rates, because the insurer wants that hospital in their network,” said Sara Collins of the nonprofit Commonwealth Fund.

. . .

Carlsbad Medical Center is owned by Community Health Systems, a chain of hospitals based in Franklin, Tenn. An investigation in 2014 by the Santa Fe New Mexican newspaper found that the three hospitals charging the highest prices in the state were all owned by that chain.

In 2015, the company paid $98 million to the federal government to settle charges that it had inflated revenue by admitting patients unnecessarily. Community Health Systems admitted no wrongdoing.

. . .

There are alternative hospitals near Carlsbad, but the closest is more than 40 minutes away, in the town of Artesia — which residents may find too far to drive to in an emergency.

. . .

Artesia General has no debt-collection suits against patients on record since 2015. Neither does Presbyterian Hospital in Albuquerque — which, at 450 licensed beds, is almost four times as large as the hospital in Carlsbad.

By contrast, other hospitals owned by Community Health Systems in New Mexico also regularly file suits over unpaid bills. Lea Regional Medical Center in Hobbs has filed almost 2,000 such suits since 2015. Mountain View Regional Medical Center in Las Cruces has filed about 2,000 suits against patients in that time; almost half of them came just this year.

In Carlsbad, these lawsuits flood the docket. District Judge Lisa Riley, who has been on the bench in Eddy County since 2011, estimated that about one-third of all civil cases that come across her desk involve unpaid medical debt.

. . .

She, too, was a target of the hospital before she became a judge. Her husband had been disputing emergency room charges when the hospital sued; the case was resolved and dismissed. (Judge Riley would not comment further, citing ethics restrictions that prohibit judges from making statements about matters that might appear in court.)

Judge Riley’s case and others from Carlsbad appear in an upcoming book called “The Price We Pay,” by Dr. Marty Makary, a surgeon at Johns Hopkins University who studies the costs of American health care and led the study of hospital suits in Virginia.

Debt collection is common in the health care industry, he said, but lawsuits are a traumatic way to force patients to pay. Normally hospitals simply refer unpaid bills to debt collectors; fewer file lawsuits and then garnish wages or place liens on homes.

In his study of Virginia, 36 percent of hospitals garnished the wages of patients owing money, with 10 percent doing so frequently. (Even his own institution, however, has come under fire for suing the poor.)

When seeking payment for medical bills, “Collections agencies may harass you with phone calls,” Dr. Makary said. “They may send a note to your credit bureau, but they’re not reaching into your paycheck.”

Many of these patients are low-paid workers with little savings. Dr. Makary’s study found that Walmart was the most common employer of those whose wages were garnished over medical bills. “These are hardworking Americans who did nothing wrong,” he said.

The cost of care differs from institution to institution, partly because hospitals have broad discretion in setting prices. Charges for the same services vary widely, even when hospitals have similar patient demographics, and the amounts billed have little relationship to quality.

If you are a hospital executive, “you could charge whatever you want,” said Dr. Makary. “You could charge $1 million for an X-ray.”

For the full story, see:

Laura Beil. “Proficient At Healing, And Suing.” The New York Times (Tuesday, September 3, 2019): D1 & D6.

(Note: ellipses added.)

(Note: the online version of the story was updated Dec. 2, 2019, and has the title “As Patients Struggle With Bills, Hospital Sues Thousands.”)

The Makary book mentioned above is:

Makary, Marty. The Price We Pay: What Broke American Health Care–and How to Fix It. New York: Bloomsbury Publishing, 2019.

Bernie Sanders Is Uncomfortable that Twitter Censored Trump

Do you think there is truth to the critique that liberals have become too censorious and too willing to use their cultural and corporate and political power to censor or suppress ideas and products that offend them?

Look, you have a former president in Trump, who was a racist, a sexist, a xenophobe, a pathological liar, an authoritarian, somebody who doesn’t believe in the rule of law. This is a bad-news guy. But if you’re asking me, do I feel particularly comfortable that the then-president of the United States could not express his views on Twitter? I don’t feel comfortable about that.

Now, I don’t know what the answer is. Do you want hate speech and conspiracy theories traveling all over this country? No. Do you want the internet to be used for authoritarian purposes and an insurrection, if you like? No, you don’t. So how do you balance that? I don’t know, but it is an issue that we have got to be thinking about. Because yesterday it was Donald Trump who was banned, and tomorrow, it could be somebody else who has a very different point of view.

I don’t like giving that much power to a handful of high-tech people. But the devil is obviously in the details, and it’s something we’re going to have to think long and hard on.

For the whole interview, see:

Klein, Ezra, interviewer. “An Unusually Optimistic Conversation With Bernie Sanders; The Vermont senator discusses the Rescue Act, cancel culture, the filibuster and more.” The Ezra Klein Show, on the New York Times web site. (Tuesday, March 23rd, 2021).

(Note: the first sentence question is by interviewer Ezra Klein. The following answer is by Senator Bernie Sanders.)

Rebates to Formulary Middlemen Are a Growing Part of Drug Costs

(p. B14) To actually sell medication, a drugmaker needs to persuade public and private health plans to place their product on the plan’s formulary, which is a list of drugs the plan is willing to purchase. That means paying middlemen rebates and discounts to choose their drug over any other rival treatments. Failure to secure favorable formulary access could mean low sales even for a highly-effective and safe medication..

. . .

“To secure that formulary position costs us more and more every year,” said Adam Gluck, Sanofi’s head of U.S. corporate affairs, in an interview. The company says that the average list price for its insulin products is up 141% since 2012 but that the net price is down 53% over that same period.

It isn’t just Sanofi facing this dynamic. Merck & Co. said last month that its average U.S. sticker price rose 3.1% in 2020 even as its average net price fell slightly. That is a sea change from recent years: In both 2015 and 2016 Merck’s average list price rose by about 10% while the net price realized by the drug giant rose by 5.5%. Nearly half of Merck’s gross sales went out the door to third parties as discounts last year. A decade ago, that tally was around 27%. Other drugmakers like Bristol-Myers Squibb report similarly high spreads between gross and net sales.

For the full commentary, see:

Charley Grant. “Pharma Giants Are Getting Their Pennies Pinched.” The Wall Street Journal (Saturday, March 13, 2021): B14.

(Note: ellipsis added.)

(Note: the online version of the commentary was updated March 12, 2021, and has the title “Pharma Giants Get Their Pennies Pinched on Drug Pricing.”)

When Incumbents Can’t Compete, They Seek to Regulate and Litigate Startups

(p. B5) Figs Inc. has fashioned itself as the Warby Parker of medical uniforms, using advertising splashed on subways and billboards to sell its form-fitting scrubs directly to nurses and doctors.

. . .

Careismatic Brands, a leader in medical apparel with brands of scrubs like Cherokee and Dickies, has pursued litigation against Figs since 2019, saying the smaller company has misled health-care workers with boasts about how its products help keep them safe.

. . .

Startups increasingly have to prepare for legal challenges from the industry they are trying to disrupt, said Arun Sundararajan, a business professor at New York University. Starting with the rise of Uber and Airbnb, “The incumbents chose regulation and litigation to try to push them back,” he said, a strategy that has been replicated.

For the full story, see:

Sara Randazzo. “Figs, a Maker of Scrubs, Fights Lawsuit Over Ads, Marketing.” The Wall Street Journal (Thursday, February 4, 2021): B5.

(Note: ellipses added.)

(Note: the online version of the story has the date February 3, 2021, and has the title “Figs Fights Lawsuit Over Scrubs Ads.”)

Optimal Size Changes With Changing Demand and Technology

(p. B1) Twirling above a strip of land at the mouth of Rotterdam’s harbor is a wind turbine so large it is difficult to photograph. The turning diameter of its rotor is longer than two American football fields end to end. Later models will be taller than any building on the mainland of Western Europe.

Packed with sensors gathering data on wind speeds, electricity output and stresses on its components, the giant whirling machine in the Netherlands is a test model for a new series of giant offshore wind turbines planned by General Electric.

. . .

(p. B5) In coming years, customers are likely to demand even bigger machines, industry executives say. On the other hand, they predict that, just as commercial airliners peaked with the Airbus A380, turbines will reach a point where greater size no longer makes economic sense.

“We will also reach a plateau; we just don’t know where it is yet,” said Morten Pilgaard Rasmussen, chief technology officer of the offshore wind unit of Siemens Gamesa Renewable Energy, the leading maker of offshore turbines.

For the full story, see:

Stanley Reed. “A Monster Wind Turbine Is Upending an Industry.” The New York Times (Saturday, January 2, 2021): B1 & B5.

(Note: ellipsis added.)

(Note: the online version of the story has the date Jan. 1, 2021, and has the same title as the print version.)

Fierce Competition in a Hazelnut-Cream-Filled Duopoly

(p. B1) MILAN — As Marianna Farina and her husband did some Christmas shopping on a windy night in Milan, she noticed lots of people walking around with small brown packages of cookies.

“I was curious,” she said. “Because I had heard about the cookie wars.”

She had found her way to a promotional pavilion set up to hype the introduction of Pan di Stelle Biscocrema, a new hazelnut cream-filled cookie by the venerable Italian breakfast brand, famous for its round cocoa cookies dotted with 11 white sugar stars.

About a month earlier, Nutella, the juggernaut of hazelnut spreads, had encroached on Pan di Stelle’s turf by introducing, after what the company said were 10 years and 120 million euros (about $133 million) in research and development, Nutella Biscuits. Ms. Farina had tried and liked them. Now she bit into the Pan di Stelle cookie. She liked it, too.

“It’s a tough one,” she said.

. . .

(p. B6) And so the Christmas cookie battle between two cultural and culinary touchstones, Pan di Stelle and Nutella, and their superpower parent companies, the pasta giant Barilla and the chocolate giant Ferrero, strikes right at the Italian aorta.

“When it comes down to Barilla and Ferrero, there can be a war,” said Michele Boroni, a marketing expert in Milan. “It’s a competition between Italy’s last food giants that have remained Italian.”

. . .

But in January 2018, Barilla made a move. It introduced jars of Pan di Stelle Crema, a spread made from “100 percent Italian hazelnuts and ‘dreamlike’ chocolate,” the company’s news release said.

Ferrero was not about to let the aggression go unanswered. The company raised the stakes in early 2019 by quietly dipping across the Italian border and testing Nutella Biscuits in other countries. In April, it rolled out the cookie in France to start spreading buzz and demand among Italians living and traveling abroad.

“This is our modus operandi,” said Claudia Millo, a Nutella spokeswoman.

For the full story, see:

Jason Horowitz and Anna Momigliano. “A War in Italy With Cream In the Middle.” The New York Times (Thursday, December 26, 2019): B1 & B6.

(Note: ellipses added.)

(Note: the online version of the story has the same date as the print version, and has the title “Italy Is in a Hazelnut Cream-Filled Civil War.”)