Industry Voices—Why 'new' isn't always better in innovating healthcare

Innovation is often measured and marked by disruption—particularly in healthcare.

Who doesn’t remember the first approved CAR-T, the first gene therapy, the first Alzheimer’s disease treatment, the first wave of biosimilars? We are always in pursuit of new breakthrough treatments, many of which change the healthcare landscape as we know it.

Meanwhile, new innovative business models all promise to offer the fastest or the cheapest care. We have a race to the top for new discoveries and a race to the bottom on cost. Amid all this change, it’s important to remember that “first,” “newest” or “cheapest” doesn’t always mean “best.”

By the end of 2023, there could be as many as 11 biosimilars for Humira on the market and even more across the broader immunology category—giving physicians and patients more options and a range of clinical considerations along with price points. While some so-called “disruptors” may run to the lowest list price option, pharmacy benefit managers like Express Scripts know that value goes well beyond sticker price. Many critical factors go into formulary decision making, including clinical efficacy, interchangeability, availability of supply, dose and concentration and patient experience, to name a few.

Decisions should always be led with clinical integrity. PBMs bring value and clinical guidance to a complicated prescription drug landscape—and, at Express Scripts, we’ve been doing this for decades. As the pioneer of pharmacy benefit management, thoughtful, patient-first innovation is in our blood.   

For example, when several biosimilars for the popular—but expensive—long-acting insulin Lantus hit the market, we didn’t rush to adopt the first option. Instead, our clinical teams evaluated the benefits provided by each product before making a formulary decision.

Ultimately, Express Scripts determined that Semglee, the first interchangeable option, would be best for patients, and we removed Lantus from our formulary when it became available. With an interchangeable product, pharmacists can automatically substitute the lower cost option at the point of sale, which further promotes patient affordability. As a result of our formulary strategy, our clients saved an estimated $20 million in 2022 alone.  

PBMs not only lead the way in ensuring patients get the highest quality drugs at the lowest possible cost, we also pave the way for smoother interactions at the pharmacy counter.  

I’ve seen firsthand through my own health journey how difficult it can be to navigate healthcare decisions on your own. I was diagnosed with stage 4 melanoma in my 30s. Given what I do for a living, I have deep knowledge of how to navigate the healthcare system, which I put to good use throughout my treatment journey. But that journey also shapes how I lead Express Scripts.  

Patients shouldn’t have to work in the healthcare industry to feel comfortable navigating their care. We need experts. We need organizations that embrace innovation while protecting patients and help them access treatment that provides the most value—both clinically and financially.  

At the critical junction in the Humira biosimilars race, we’re focused on rigorously evaluating new options as well as the market holistically to help ensure our clients and consumers are getting the best outcomes at the best value. Because sometimes the best disruption is driven by solutions-oriented expertise.

Adam Kautzner is president of pharmacy benefit manager Express Scripts.