DOES MEDICARE REIMBURSEMENT DRIVE UP DRUG LAUNCH PRICES? David B. Ridley and Chung-Ying Lee* Abstract—Medicare reimburses health care providers for the drugs they Before 2005, Medicare paid health care providers an administer. Since 2005, it has reimbursed based on the past price of the drug. amount largely unrelated to the actual price. Medicare- Reimbursement on past prices could motivate manufacturers to set higher launch prices because providers become less sensitive to price and because reimbursed providers based on AWP, which officially stood provider reimbursement is higher if past prices were higher. Using data on for average wholesale price but was widely known as drug launch prices between 1999 and 2010, we estimate that reimbursement “ain’t what’s paid.” Beginning in 2005, Medicare reimbursed based on past prices caused launch prices to rise dramatically. The evidence is consistent with the 2018 claim from Medicare’s administrator that it providers based on average sales price (ASP) (Jacobson et al., “creates a perverse incentive for manufacturers to set higher prices.” 2010; Yurukoglu, Liebman, & Ridley, 2017). ASP is the av- erage price of purchases made by providers in the previous six months. Hence, in 2005, reimbursement changed from an I. Introduction amount unrelated to the actual price to an average of lagged prices. Nthepastdecade,launchpricesforsomedrugs,especially Because some of the effects of the reimbursement mecha- Downloaded from http://direct.mit.edu/rest/article-pdf/102/5/980/1887292/rest_a_00849.pdf by guest on 16 June 2021 16 on by guest http://direct.mit.edu/rest/article-pdf/102/5/980/1887292/rest_a_00849.pdf from Downloaded Icancer drugs, have been much higher than earlier genera- nism are subtle, we use a model to provide intuition. In the tions of the drugs (Howard et al., 2015). One cause for high model, we show that when insurers reimburse providers based drug prices in the United States could be the way Medicare on lagged prices, manufacturers choose a high launch price pays health care providers. According to a 2018 speech by for two reasons. The first reason is straightforward: providers the head of the Centers for Medicare and Medicaid Services, are less sensitive to the price when reimbursement covers a “Medicare pays Part B providers for drugs at an amount equal portion of the price. The second reason is subtle: a provider’s to the average price the drug sells for plus a six percent add-on current reimbursement depends on past prices. Hence, while fee. This payment structure creates a perverse incentive for aproviderpreferslowcurrentprices,theproviderprefers manufacturers to set higher prices” (Verma, 2018). Private high past prices because the insurer pays the provider more insurers often mimic Medicare (Clemens & Gottlieb, 2017), when past prices are higher. Hence, firms “invest” in a high so the policy affects Medicare and private insurers. launch price, higher than the profit-maximizing current price, We investigate whether the 2005 change to reimbursement in order to secure higher reimbursement for the provider in based on past prices caused an increase in launch prices. the future. By setting a higher launch price, the future reim- We compare drug launch prices before and after the reim- bursement is higher, so future demand is higher, and the firm bursement change. We use launch-price variation within a can charge a higher price in the future. We illustrate these ef- molecule for drugs launching different dosage forms of the fects using a model of reimbursement in a market with rising same molecule in different years. We also use launch-price willingness to pay. variation across molecules for drugs in the same class. Fi- We estimate that a 2005 change in reimbursement policy nally, we compare launch prices for drugs reimbursed under caused launch prices for outpatient drugs to double. This is different payment mechanisms. For some drugs, including re- the first study to show that the 2005 policy increased launch tail drugs and some provider-administered drugs, Medicare prices for branded drugs administered by providers. Previ- reimbursement did not change to a markup on the average ous studies examined the effect of the 2005 policy change on sales price, and these drugs function as a control group. product mix (Jacobson et al., 2010), shortages (Yurukoglu Medicare and other insurers do not directly pay drug manu- et al., 2017), and vertical integration (Alpert, Hsi, & Jacob- facturers. Instead, Medicare reimburses health care providers son, 2017). that administer the drugs. The way in which an insurer Previous research also examined how other government like Medicare reimburses a health care provider influences reimbursement policies affect drug manufacturer strategy. the price that the drug manufacturer charges the provider Competition among drug manufacturers is weaker when (see figure 1). the government regulates prices (Ekelund & Persson, 2003) or requires that a manufacturer give the government its Received for publication June 18, 2018. Revision accepted for publication lowest price among its customers (Scott Morton, 1997). April 15, 2019. Editor: Amitabh Chandra. Government-provided insurance can offset the deadweight ∗Ridley: Duke University; Lee: National Taiwan University. loss of monopoly unless the manufacturer fully captures the We are grateful for helpful comments from Peter Arcidiacono, Ernst Berndt, Colleen Carey, David Howard, Eli Liebman, Ryan McDevitt, and increase in willingness to pay through a higher price (Lak- Su Zhang, and seminar participants at Duke University, Emory University, dawalla & Sood, 2009). Government policy can also induce and Yale University. We also thank participants at the Congressional Bud- manufacturers to launch new versions of products in order to get Office annual meeting, the International Health Economics Association Congress, the International Industrial Organization Conference, the Life reset prices (Ikegami, Ikeda, & Kawai, 1998; Duggan & Scott Sciences Symposium, and the Shanghai University of Finance and Eco- Morton, 2006). We examine launch prices for new branded nomics Industrial Organization Conference. drugs, rather than generic drugs, because competition tends A supplemental appendix is available online at http://www.mitpress journals.org/doi/suppl/10.1162/rest_a_00849. to suppress generic drug prices (Scott Morton, 1999; The Review of Economics and Statistics,December2020,102(5):980–993 © 2019 by the President and Fellows of Harvard College and the Massachusetts Institute of Technology https://doi.org/10.1162/rest_a_00849 DOES MEDICARE REIMBURSEMENT DRIVE UP DRUG LAUNCH PRICES 981 FIGURE 1.—FLOW OF FUNDS FOR PROVIDER-ADMINISTERED DRUGS Amanufacturer(throughawholesaleroraspecialtypharmacy)sellsadrugtoaprovider(aphysicianclinicorhospital),andtheprovideristhenreimbursed by Medicare or a private insurer. The way in which Medicare reimburses the provider influences the price charged by the manufacturer. FIGURE 2.—MEDICARE SPENDING FOR OUTPATIENT PROVIDER-ADMINISTERED DRUGS Downloaded from http://direct.mit.edu/rest/article-pdf/102/5/980/1887292/rest_a_00849.pdf by guest on 16 June 2021 16 on by guest http://direct.mit.edu/rest/article-pdf/102/5/980/1887292/rest_a_00849.pdf from Downloaded Medicare outpatient provider-administered (Part B) drug spending has accelerated in recent years, perhaps because drugs launched since the 2005 policy have had higher prices and constitute a growing share of drugs in use. Source: Authors’ analysis using data from the Medicare Payment Advisory Commission (2017). Reiffen & Ward, 2005; Grabowski, Ridley, & Schulman, We are interested in the effect of a change in provider reim- 2007; Ching, 2010). bursement under Medicare Part B. Part B drug spending was The study contributes to the literature on dynamic pricing. $25.7 billion in 2015, with $17 billion for drugs administered Previous research showed that a firm will launch at a price in physician clinics and $8.7 billion for drugs administered in above the current profit-maximizing price if regulations pro- hospital outpatient departments (see figure 2). Under Medi- hibit price increases (Abbott, 1995), especially if consumers care Part B, health care providers buy drugs from manufac- are shortsighted (Ridley & Zhang, 2017) and if the firm is turers (through a wholesaler). For example, a provider in a uncertain about demand (Shajarizadeh & Hollis, 2015). We cancer clinic would administer pegfilgrastim to a patient to identify a new reason for high launch prices: reimbursement stimulate her level of white blood cells. In 2014, Medicare based on lagged prices. spent more than $1 billion on pegfilgrastim to treat cancer patients (U.S. Government Accountability Office, 2016). A. Background on Drugs Administered Before 2005, Medicare paid providers an amount largely by Providers in Medicare unrelated to the actual price. Medicare reimbursed providers based on AWP, which officially stood for average wholesale In the United States, Medicare provides health insurance price but was widely known as “ain’t what’s paid.” Some for people over age 65 and the disabled. Medicare Part A manufacturers inflated the list price while holding down the covers inpatient hospital stays, Part B covers care in physician actual price in order to increase the spread received by the clinics and hospital outpatient departments, and Part D covers provider (Berndt & Newhouse, 2010; Alpert et al., 2013). In- prescription drugs purchased through a retail pharmacy or flating the list price