But despite plenty of candidates, a less forgiving reimbursement environment may mean the days of 90% margins on life-saving drugs may be winding down fast.
Take a company like Questcor (QCOR), for example. The company has built an extremely lucrative franchise out of its only drug, a hormone gel marketed under the name Acthar that currently sells for $28,000 per five-injection vial.
Acthar was originally developed to treat rare pediatric seizures and has since been prescribed more widely as a last-ditch treatment for non-cortisone-responsive multiple sclerosis and other immune disorders.
Although expanding the addressable market definitely helped QCOR compound its revenue at a rate above 50% a year over the past decade, raising the price per dose by approximately 70,000% since 2001 has been the real factor that initially made this one-drug operation a Wall Street star.
Unfortunately, charging the equivalent of a middle-class American’s annual salary for a week’s supply of a life-saving drug that once cost $40 may have won investor applause in the past, but it now makes QCOR an easy target for public health advocates, cost-conscious bureaucrats and regulators alike.
And given the complexities of the system through which the company has billed insurance carriers full price while bending copayments to keep Acthar nominally affordable, even the threat of additional scrutiny raises the risk of the entire structure breaking down.
Like other biotech companies, QCOR pays a significant rebate to the states and federal government for every injection that participants in Medicare, Medicaid and other programs receive.
As such, implementation of the Affordable Care Act naturally cuts into the 90% gross profit margins QCOR currently enjoys. Management has estimated that 30% of sales into some of its fastest-growing indications – multiple sclerosis and kidney disease – represent Medicare patients as it is.
Factor in the ongoing expansion of Medicaid, which opens up a 27% effective discount for millions of Americans who would otherwise not have qualified for coverage, and today’s rich margins can only deteriorate from here.
Meanwhile, Obamacare presents a direct challenge to the company’s efforts to ensure that private health insurers have more $28,000 bills to pay.
In many conventional health plans, a specialty drug like Acthar is classified as “Tier 5,” which means patients can pick up 25% of the retail pharmacy cost once they’ve met their annual deductible. The good news is that $7,000 for a one-week course of injections will eventually trigger the out of pocket maximum on every qualified Obamacare individual plan and will take families about 55% to that threshold.
The bad news, of course, is that $7,000 is a lot of cash for many families to come up with. And while the health plans listed on the insurance exchange vary widely, many Bronze and even Silver policies still require patients themselves to pay 30% to 40% of the cost of a Tier 5 drug even afterthe policy starts sharing the load.
No copay, no injection. No injection, no revenue for the drug manufacturer. In the past, the pharmaceutical industry has skirted the dilemma by contributing heavily to medical charities that cover the gap between patient funds and what the insurance company – if any – will pay.
In theory, the system is the best of all possible worlds. But recently, the hint of executive conflicts of interest was enough to force the Chronic Disease Fund, one of the biggest of these charities, to stop writing grants that even give the appearance of directly promoting a particular donor company’s drugs.