By Anthony Mazzarese, PharmD, MSPBA

The question the nation is asking themselves right now is, “Where will the United States be at the end of President Donald Trump’s time in office?”

The simple answer is that no one has any idea. We are about to embark on a journey into the unknown. As such, it is still unknown how the Trump administration will impact specialty pharmacy.

Specialty therapies were a hot topic during the presidential race, and the candidates both stated that skyrocketing drug prices need to be addressed. What legislation will President Trump enact that will affect health care and specialty pharmacy?

President Trump has vowed to repeal the Affordable Care Act (ACA), which is a very controversial subject. Millions of Americans have gained health insurance as a result of the ACA, but it has been shrouded in criticism ever since. Even the launch of the healthcare.gov website, which was behind schedule and way over budget, caused significant headlines.

Will the ACA exist at the end of Trump’s time in office? The Republicans now control the House of Representatives, Senate, and the White House, so it is safe to assume that the ACA will not exist in its current form. There will be remnants of the ACA in whatever follows, but it will be difficult to enact drastic changes, despite the need.

There is a health care expenditure epidemic in the United States that is causing health care inflation to outpace GDP, and there is no solution in sight. By 2020, it is expected that health care will account for 20% of GDP.

The increasing number of patients over 65, in addition to the excessive growth of specialty pharmacy, is causing stress on the health care system. There will be a projected 10,000 baby boomers turning 65 every day for the next 15 years. This is too large of a problem to be solved in the next 8 years. Not only is the sheer number of patients part of the problem, but their outlook on health care is also.

Patients currently have the attitude that they want the best care, right away, and at no charge. With this mindset, it is hard to imagine how health care costs will be reduced long term. Temporary solutions will continue to filter in and out of Washington DC, of which, all will fail until the mindset of the nation is geared towards fiscally-responsible health care.

Look at the various therapies that extend life expectancy by days, not years. Should this expense to the health care system be allowed when those funds can be used to treat someone who can get a more significant return on investment?

Health care under Trump may start to be addressed more like a business, which is something that the United States desperately needs. Each decision needs to be weighed against other potential options. There is only so much money to go around.

Let’s evaluate two potential patients. Patient A is a 70-year-old male with prostate cancer, who can take a specialty oncolytic that will cost $100,000 and extend his life an expected 6 months. Patient B is a 70-year-old male who needs a hip and knee replacement that will cost $100,000, which will significantly increase mobility and decrease his need for other social services due to his immobility.

If you oversaw a health plan, which patient would you spend the allotted $100,000? Which is a better business decision?

One major problem is getting the public to understand that the $100,000 for an additional 6 months of life is not worth the price tag. This is very different mindset from the current view that if it exists and will show marginal improvement, the patient should get the treatment.

Under these conditions, there may be a decrease in utilization of oncolytic treatments that do not routinely get patients to remission or a cure. This decreased oncolytic utilization may be a catalyst for innovative drug development.

Medications that are considered clinically inferior should receive lower reimbursements by all health plans or not be paid for at all. Why should health plans continue to pay out money for therapies that are not going to produce a high enough return on investment? These therapies should be restricted to free up funds that can benefit another patient.

Denying patient care for the betterment of the health plan or the nation is a concept that the United States needs to adopt to get our health care spending under control. Other single payer systems already are making decisions that deny patients care, but it does not seem to be as much of a problem in those nations.

President Trump will make changes to health care, but what exactly those changes will be is not yet clear. He states that he is going to repeal the ACA, but what will be his solution to replace it? The next 4 or 8 years should be interesting and produce marginal improvements, but with the number of patients turning age 65 and the mindset of the public, how much can change?

Anthony Mazzarese is a graduate of The University of Pittsburgh School of Pharmacy.  He received his MSPBA, a 12-month, executive-style graduate education program designed for working professionals striving to be tomorrow’s leaders in the business of medicines, from the University of Pittsburgh in 2016.  He is the Pharmacist-in-Charge at Giant Eagle Specialty Pharmacy.  His practice is focused on improving medication compliance and overall well-being in the areas of HIV, auto-immune disorders, oncology and organ transplantation.

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The United States is in desperate need of an overhaul to the current health care system.
