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Analysis of State-Level Drug Pricing Transparency Laws in the United States

Analysis of State-Level Drug Pricing Transparency Laws in the United States Research Letter | Health Policy Analysis of State-Level Drug Pricing Transparency Laws in the United States Martha S. Ryan, BS; Neeraj Sood, PhD Introduction Increasing drug prices strain the budgets of consumers and public payers, including Medicaid. Faced Supplemental content with an opaque drug supply chain, few people outside of the pharmaceutical industry know which Author affiliations and article information are 1,2 supply chain participants are making excess profits and where to target policy solutions. Some listed at the end of this article. states have responded by passing laws to increase drug price transparency in the supply chain. In this study, we analyzed state drug price transparency laws to assess their potential to improve transparency in the drug supply system. Prior research has focused on state laws requiring manufacturers to report research and development expenditures and efforts to control costs 3,4 through drug importation or manufacturer price controls. To our knowledge, this is the first study to focus on state laws to improve drug price transparency across the supply chain. Methods In this cross-sectional study, we searched the National Conference of State Legislatures prescription drug database for transparency laws, restricting our search to laws enacted between January 1, 2015, and December 31, 2018. We coded each law by which entity in the drug distribution system (ie, manufacturers, wholesalers, pharmacy benefit managers [PBMs], pharmacies, insurers, or a combination) was required to provide the information. We also evaluated whether laws would reveal Table 1. Reporting Requirement Content in Transparency Laws Characteristic States, No. Informative 6 Requirement Manufacturers must report net price or profits 3 Wholesaler must report net price or profits 0 Pharmacy must report net price or profits 0 Pharmacy benefit manager must report rebates or profits 3 Insurer must report net price or profits 1 Includes Maine S 484, Nevada SB 539, and Oregon 4005. Includes Connecticut H 5384, Louisiana SB 283/282, and Nevada SB 539. Includes Vermont S 92. Table 2. Number of States Targeting Different Types of Entities Through Transparency Legislation Target of Reporting Requirement States, No. Pharmacy benefit managers 15 Insurers 11 Manufacturers 8 Pharmacies 2 Wholesalers 0 Total number of states exceeds 35 because several states passed multiple laws, and state reporting requirements may target multiple segments of the supply chain. Open Access. This is an open access article distributed under the terms of the CC-BY License. JAMA Network Open. 2019;2(9):e1912104. doi:10.1001/jamanetworkopen.2019.12104 (Reprinted) September 25, 2019 1/3 JAMA Network Open | Health Policy Analysis of State-Level Drug Pricing Transparency Laws in the United States previously unavailable information in the form of profits or real transaction prices, including rebates and concessions, for supply chain participants. Because knowing real transaction prices is crucial to determining who is earning excess profits in the supply chain and for targeting policy solutions, we labeled transparency laws resulting in new disclosure of this information as informative; laws mandating reporting of information that was already available from other sources, including wholesale acquisition costs, list prices, or other intermediary prices, were labeled uninformative. The methods for how we labeled each law are shown in the eTable in the Supplement.Wefollowed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cross-sectional studies. Institutional review board approval was not required because the study used only public data on state laws and not human participants as defined by Common Rule 45 CFR part 46.102. Data analysis was conducted from October 1, 2018, to February 2, 2019. Results Of 166 drug pricing laws identified, 35 laws passed in 22 states included a transparency component, but only 7 laws passed in 6 states were deemed informative (Table 1). Two states required that net price be reported—by insurers in Vermont and by manufacturers in Maine. Only Oregon and Nevada passed laws that required that profits be reported by manufacturers. Laws in Connecticut, Louisiana, and Nevada required that PBMs report rebates in aggregate but not at the individual-drug level. Uninformative transparency laws commonly required that supply chain participants disclose pricing or formulary design methodology, provide advance notice of list price increases, or register with a government regulatory body. Most states with transparency laws targeted PBMs (15 states) or insurers (11 states); 2 states passed laws that targeted pharmacies, and no states passed laws that targeted wholesalers (Table 2). Only Nevada and Vermont passed laws that targeted 3 distinct supply chain segments (ie, manufacturer, insurer, and PBM); no state passed laws that targeted more than 3 supply chain segments. Importantly, no state passed laws that together revealed true transaction prices or profits across all supply chain segments. Discussion The process of manufacturing, distributing, and paying for pharmaceuticals involves numerous commercial entities, including drug manufacturers, wholesalers, pharmacies, PBMs, and insurers. Real transaction prices, including rebates and discounts at each stage of this process, are needed to understand profits and distribution of rents across these supply chain segments. Without this information, regulators cannot target policy solutions at the segments making excessive profits. Despite many recent state laws about price transparency, we found that most of them were insufficient to reveal true transaction prices, and no state passed legislation that provided effective transparency across the entire supply chain. To ensure drug price legislation is useful, policy makers should require that real price information, including discounts and rebates, is reported by all supply chain participants. Ideally, this information should be available for drugs with the largest effect on the state’s budget or largest price increases. If requiring such disclosure at the individual-drug level would invite legal challenge, states should at least require each supply chain segment to report aggregate profits from sales in that state. ARTICLE INFORMATION Accepted for Publication: August 7, 2019 Published: September 25, 2019. doi:10.1001/jamanetworkopen.2019.12104 JAMA Network Open. 2019;2(9):e1912104. doi:10.1001/jamanetworkopen.2019.12104 (Reprinted) September 25, 2019 2/3 JAMA Network Open | Health Policy Analysis of State-Level Drug Pricing Transparency Laws in the United States Correction: This article was corrected on October 23, 2019, to fix typographical errors in the eTable in the Supplement. Open Access: This is an open access article distributed under the terms of the CC-BY License.©2019RyanMSetal. JAMA Network Open. Corresponding Author: Neeraj Sood, PhD, Sol Price School of Public Policy, University of Southern California, 635 Downey Way, VPD 514M, Los Angeles, CA 90089-3333 (nsood@usc.edu). Author Affiliations: Sol Price School of Public Policy, University of Southern California, Los Angeles; Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles. Author Contributions: Ms Ryan and Dr Sood had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Sood. Acquisition, analysis, or interpretation of data: Ryan. Drafting of the manuscript: Both authors. Critical revision of the manuscript for important intellectual content: Both authors. Statistical analysis: Sood. Administrative, technical, or material support: Ryan. Supervision: Sood. Conflict of Interest Disclosures: Dr Sood reported receiving personal fees from the American Medical Association, Virta Health, China Development Research Foundation, Pharmaceutical Research and Manufacturers of America, Crueger Dickinson LLC, Precision Health Economics, andH&H Wholesale outside of the submitted work. No other disclosures were reported. REFERENCES 1. Cefalu WT, Dawes DE, Gavlak G, et al; Insulin Access and Affordability Working Group. Insulin Access and Affordability Working Group: conclusions and recommendations. Diabetes Care. 2018;41(6):1299-1311. doi:10. 2337/dci18-0019 2. Council of Economic Advisers, Executive Office of the President. Reforming biopharmaceutical pricing at home and abroad. https://www.whitehouse.gov/wp-content/uploads/2017/11/CEA-Rx-White-Paper-Final2.pdf. Accessed July 1, 2019. 3. Horvath JC, Anderson GF. The states as important laboratories for federal prescription drug cost-containment efforts. JAMA. 2019;321(16):1561-1562. doi:10.1001/jama.2019.2189 4. Sarpatwari A, Avorn J, Kesselheim AS. State initiatives to control medication costs: can transparency legislation help? N Engl J Med. 2016;374(24):2301-2304. doi:10.1056/NEJMp1605100 5. National Conference of State Legislatures. Statewide prescription drug database: 2015-present. http://www.ncsl. org/research/health/prescription-drug-statenet-database.aspx. Accessed December 14, 2018. 6. Sood N, Shih T, Van Nuys K, Goldman DP. Follow the money: the flow of funds in the pharmaceutical distribution system. https://www.healthaffairs.org/do/10.1377/hblog20170613.060557/full/. Accessed June 13, 2019. SUPPLEMENT. eTable. Method of Classifying Laws eReferences. JAMA Network Open. 2019;2(9):e1912104. doi:10.1001/jamanetworkopen.2019.12104 (Reprinted) September 25, 2019 3/3 Supplementary Online Content Ryan MS, Sood N. Analysis of state-level drug pricing transparency laws in the United States. JAMA Netw Open. 2019;2(9):e1912104. doi:10.1001/jamanetworkopen.2019.12104 eTable. Method of Classifying Laws eReferences. This supplementary material has been provided by the authors to give readers additional information about their work. © 2019 Ryan MS et al. JAMA Network Open. eTable. Method of Classifying Laws Profit Margin State & Net Whole- Manu- Bill/Rule/Statute Year Target(s) price Rebates saler PBM facturer Pharmacy Informative? AK HB 240 2018 PBMs No No No No No No No AR S 466 2015 Insurers No No No No No No No AR A 815 2017 Insurers No No No No No No No Manufacturer, CA SB 17 2017 Insurer No No No No No No No Manufacturers, PBMs, CT H 5384 2018 Insurers No Yes No No No No Yes CT S 811 2015 Insurers No No No No No No No DE HB 284 2016 PBMs No No No No No No No FL HB 589 2017 Pharmacies No No No No No No No HI H 252 2015 PBMs No No No No No No No HI H 261 2015 Insurers No No No No No No No KY SB 117 2016 PBMs No No No No No No No KY SB 5 2018 PBMs No No No No No No No LA H 436 2017 Manufacturers No No No No No No No LA SB 59 2017 PBMs No No No No No No No LA H 568 2015 Pharmacies No No No No No No No LA SB 282 2018 Insurers No Yes No No No No Yes LA SB 283 2018 PBMs No Yes No No No No Yes ME S 484/ LD 1406 2018 Manufacturers Yes No No No No No Yes ME S 229 2015 Insurers No No No No No No No ME H 788 2016 PBMs No No No No No No No MD 15-1628.1 2015 PBMs No No No No No No No MD 15-1628.1 2018 PBMs No No No No No No No MN 151.214 2017 PBMs No No No No No No No MT S 211 2015 PBMs No No No No No No No Manufacturers, PBMs, NV SB 539 2017 Insurers Yes Yes No No Yes No Yes NH HB 1418 2018 Manufacturers No No No No No No No NJ N.J.A.C. 11:4- 62 2017 PBMs No No No No No No No Manufacturer, OR H 4005 2018 Insurer No No No No Yes No Yes PA A 169 2016 PBMs No No No No No No No RI S 2467 2016 PBMs No No No No No No No SD S 118 2015 Insurers No No No No No No No TX H 1624 2015 Insurers No No No No No No No TX H 1227 2017 Insurers No No No No No No No Manufacturer, VT S 216 / A 165 2016 Insurer No No No No No No No © 2019 Ryan MS et al. JAMA Network Open. Manufacturers, Insurers, VT S 92/A 193 2018 PBMs Yes No No No No No Yes We classify each law as informative if it requires a supply chain participant (such as insurers, PBMs, manufacturers) to disclose either 1) rebate amount, 2) profit, or 3) net price. We base these criteria on research findings that rebates, profits and net prices are crucial to determining who is responsible for high drug costs and for examining the potential effects of policy proposals to control drug costs, including removing safe harbor protections for rebates, using external reference 1-5 pricing and eliminating spread pricing. To corroborate our approach, we asked a second analyst unfamiliar with our study to independently re-code our sample of laws using the same criteria. This second coding agreed with our original coding in 35 out of 35 cases. eReferences. 1. Wineinger NE, Zhang Y, Topol EJ. Trends in Prices of Popular Brand-Name Prescription Drugs in the United States. JAMA Network Open. 2019;2(5):e194791-e194791. 2. Sood N, Shih T, Van Nuys K, Goldman DP. Follow The Money: The Flow Of Funds In The Pharmaceutical Distribution System. Health Affairs Blog. 2017. https://www.healthaffairs.org/do/10.1377/hblog20170613.060557/full/. Accessed June 13, 3. Dusetzina SB, Conti RM, Yu NL, Bach PB. Association of Prescription Drug Price Rebates in Medicare Part D With Patient Out-of-Pocket and Federal Spending. JAMA Internal Medicine. 2017;177(8):1185-1188. 4. Council of Economic Advisers, Executive Office of the President. Reforming Biopharmaceutical Pricing at Home and Abroad. https://www.whitehouse.gov/wp- content/uploads/2017/11/CEA-Rx-White-Paper-Final2.pdf. Published February 9, 2018. Accessed July 1, 2019. 5. Senate Committee on Finance. Description of the Chairm Pricing Reduction Act (PDPRA) of 2019. https://www.finance.senate.gov/imo/media/doc/FINAL%20Description%20of%20the%20 Chairman's%20Mark%20for%20the%20Prescription%20Drug%20Pricing%20Reduction% 20Act%20of%202019.pdf. Published July 25, 2019. Accessed July 27, 2019. © 2019 Ryan MS et al. JAMA Network Open. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Network Open American Medical Association

Analysis of State-Level Drug Pricing Transparency Laws in the United States

Ryan, Martha S.; Sood, Neeraj
JAMA Network Open , Volume 2 (9) – Sep 25, 2019
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American Medical Association
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Copyright 2019 Ryan MS et al. JAMA Network Open.
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10.1001/jamanetworkopen.2019.12104
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Abstract

Research Letter | Health Policy Analysis of State-Level Drug Pricing Transparency Laws in the United States Martha S. Ryan, BS; Neeraj Sood, PhD Introduction Increasing drug prices strain the budgets of consumers and public payers, including Medicaid. Faced Supplemental content with an opaque drug supply chain, few people outside of the pharmaceutical industry know which Author affiliations and article information are 1,2 supply chain participants are making excess profits and where to target policy solutions. Some listed at the end of this article. states have responded by passing laws to increase drug price transparency in the supply chain. In this study, we analyzed state drug price transparency laws to assess their potential to improve transparency in the drug supply system. Prior research has focused on state laws requiring manufacturers to report research and development expenditures and efforts to control costs 3,4 through drug importation or manufacturer price controls. To our knowledge, this is the first study to focus on state laws to improve drug price transparency across the supply chain. Methods In this cross-sectional study, we searched the National Conference of State Legislatures prescription drug database for transparency laws, restricting our search to laws enacted between January 1, 2015, and December 31, 2018. We coded each law by which entity in the drug distribution system (ie, manufacturers, wholesalers, pharmacy benefit managers [PBMs], pharmacies, insurers, or a combination) was required to provide the information. We also evaluated whether laws would reveal Table 1. Reporting Requirement Content in Transparency Laws Characteristic States, No. Informative 6 Requirement Manufacturers must report net price or profits 3 Wholesaler must report net price or profits 0 Pharmacy must report net price or profits 0 Pharmacy benefit manager must report rebates or profits 3 Insurer must report net price or profits 1 Includes Maine S 484, Nevada SB 539, and Oregon 4005. Includes Connecticut H 5384, Louisiana SB 283/282, and Nevada SB 539. Includes Vermont S 92. Table 2. Number of States Targeting Different Types of Entities Through Transparency Legislation Target of Reporting Requirement States, No. Pharmacy benefit managers 15 Insurers 11 Manufacturers 8 Pharmacies 2 Wholesalers 0 Total number of states exceeds 35 because several states passed multiple laws, and state reporting requirements may target multiple segments of the supply chain. Open Access. This is an open access article distributed under the terms of the CC-BY License. JAMA Network Open. 2019;2(9):e1912104. doi:10.1001/jamanetworkopen.2019.12104 (Reprinted) September 25, 2019 1/3 JAMA Network Open | Health Policy Analysis of State-Level Drug Pricing Transparency Laws in the United States previously unavailable information in the form of profits or real transaction prices, including rebates and concessions, for supply chain participants. Because knowing real transaction prices is crucial to determining who is earning excess profits in the supply chain and for targeting policy solutions, we labeled transparency laws resulting in new disclosure of this information as informative; laws mandating reporting of information that was already available from other sources, including wholesale acquisition costs, list prices, or other intermediary prices, were labeled uninformative. The methods for how we labeled each law are shown in the eTable in the Supplement.Wefollowed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cross-sectional studies. Institutional review board approval was not required because the study used only public data on state laws and not human participants as defined by Common Rule 45 CFR part 46.102. Data analysis was conducted from October 1, 2018, to February 2, 2019. Results Of 166 drug pricing laws identified, 35 laws passed in 22 states included a transparency component, but only 7 laws passed in 6 states were deemed informative (Table 1). Two states required that net price be reported—by insurers in Vermont and by manufacturers in Maine. Only Oregon and Nevada passed laws that required that profits be reported by manufacturers. Laws in Connecticut, Louisiana, and Nevada required that PBMs report rebates in aggregate but not at the individual-drug level. Uninformative transparency laws commonly required that supply chain participants disclose pricing or formulary design methodology, provide advance notice of list price increases, or register with a government regulatory body. Most states with transparency laws targeted PBMs (15 states) or insurers (11 states); 2 states passed laws that targeted pharmacies, and no states passed laws that targeted wholesalers (Table 2). Only Nevada and Vermont passed laws that targeted 3 distinct supply chain segments (ie, manufacturer, insurer, and PBM); no state passed laws that targeted more than 3 supply chain segments. Importantly, no state passed laws that together revealed true transaction prices or profits across all supply chain segments. Discussion The process of manufacturing, distributing, and paying for pharmaceuticals involves numerous commercial entities, including drug manufacturers, wholesalers, pharmacies, PBMs, and insurers. Real transaction prices, including rebates and discounts at each stage of this process, are needed to understand profits and distribution of rents across these supply chain segments. Without this information, regulators cannot target policy solutions at the segments making excessive profits. Despite many recent state laws about price transparency, we found that most of them were insufficient to reveal true transaction prices, and no state passed legislation that provided effective transparency across the entire supply chain. To ensure drug price legislation is useful, policy makers should require that real price information, including discounts and rebates, is reported by all supply chain participants. Ideally, this information should be available for drugs with the largest effect on the state’s budget or largest price increases. If requiring such disclosure at the individual-drug level would invite legal challenge, states should at least require each supply chain segment to report aggregate profits from sales in that state. ARTICLE INFORMATION Accepted for Publication: August 7, 2019 Published: September 25, 2019. doi:10.1001/jamanetworkopen.2019.12104 JAMA Network Open. 2019;2(9):e1912104. doi:10.1001/jamanetworkopen.2019.12104 (Reprinted) September 25, 2019 2/3 JAMA Network Open | Health Policy Analysis of State-Level Drug Pricing Transparency Laws in the United States Correction: This article was corrected on October 23, 2019, to fix typographical errors in the eTable in the Supplement. Open Access: This is an open access article distributed under the terms of the CC-BY License.©2019RyanMSetal. JAMA Network Open. Corresponding Author: Neeraj Sood, PhD, Sol Price School of Public Policy, University of Southern California, 635 Downey Way, VPD 514M, Los Angeles, CA 90089-3333 (nsood@usc.edu). Author Affiliations: Sol Price School of Public Policy, University of Southern California, Los Angeles; Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles. Author Contributions: Ms Ryan and Dr Sood had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Sood. Acquisition, analysis, or interpretation of data: Ryan. Drafting of the manuscript: Both authors. Critical revision of the manuscript for important intellectual content: Both authors. Statistical analysis: Sood. Administrative, technical, or material support: Ryan. Supervision: Sood. Conflict of Interest Disclosures: Dr Sood reported receiving personal fees from the American Medical Association, Virta Health, China Development Research Foundation, Pharmaceutical Research and Manufacturers of America, Crueger Dickinson LLC, Precision Health Economics, andH&H Wholesale outside of the submitted work. No other disclosures were reported. REFERENCES 1. Cefalu WT, Dawes DE, Gavlak G, et al; Insulin Access and Affordability Working Group. Insulin Access and Affordability Working Group: conclusions and recommendations. Diabetes Care. 2018;41(6):1299-1311. doi:10. 2337/dci18-0019 2. Council of Economic Advisers, Executive Office of the President. Reforming biopharmaceutical pricing at home and abroad. https://www.whitehouse.gov/wp-content/uploads/2017/11/CEA-Rx-White-Paper-Final2.pdf. Accessed July 1, 2019. 3. Horvath JC, Anderson GF. The states as important laboratories for federal prescription drug cost-containment efforts. JAMA. 2019;321(16):1561-1562. doi:10.1001/jama.2019.2189 4. Sarpatwari A, Avorn J, Kesselheim AS. State initiatives to control medication costs: can transparency legislation help? N Engl J Med. 2016;374(24):2301-2304. doi:10.1056/NEJMp1605100 5. National Conference of State Legislatures. Statewide prescription drug database: 2015-present. http://www.ncsl. org/research/health/prescription-drug-statenet-database.aspx. Accessed December 14, 2018. 6. Sood N, Shih T, Van Nuys K, Goldman DP. Follow the money: the flow of funds in the pharmaceutical distribution system. https://www.healthaffairs.org/do/10.1377/hblog20170613.060557/full/. Accessed June 13, 2019. SUPPLEMENT. eTable. Method of Classifying Laws eReferences. JAMA Network Open. 2019;2(9):e1912104. doi:10.1001/jamanetworkopen.2019.12104 (Reprinted) September 25, 2019 3/3 Supplementary Online Content Ryan MS, Sood N. Analysis of state-level drug pricing transparency laws in the United States. JAMA Netw Open. 2019;2(9):e1912104. doi:10.1001/jamanetworkopen.2019.12104 eTable. Method of Classifying Laws eReferences. This supplementary material has been provided by the authors to give readers additional information about their work. © 2019 Ryan MS et al. JAMA Network Open. eTable. Method of Classifying Laws Profit Margin State & Net Whole- Manu- Bill/Rule/Statute Year Target(s) price Rebates saler PBM facturer Pharmacy Informative? AK HB 240 2018 PBMs No No No No No No No AR S 466 2015 Insurers No No No No No No No AR A 815 2017 Insurers No No No No No No No Manufacturer, CA SB 17 2017 Insurer No No No No No No No Manufacturers, PBMs, CT H 5384 2018 Insurers No Yes No No No No Yes CT S 811 2015 Insurers No No No No No No No DE HB 284 2016 PBMs No No No No No No No FL HB 589 2017 Pharmacies No No No No No No No HI H 252 2015 PBMs No No No No No No No HI H 261 2015 Insurers No No No No No No No KY SB 117 2016 PBMs No No No No No No No KY SB 5 2018 PBMs No No No No No No No LA H 436 2017 Manufacturers No No No No No No No LA SB 59 2017 PBMs No No No No No No No LA H 568 2015 Pharmacies No No No No No No No LA SB 282 2018 Insurers No Yes No No No No Yes LA SB 283 2018 PBMs No Yes No No No No Yes ME S 484/ LD 1406 2018 Manufacturers Yes No No No No No Yes ME S 229 2015 Insurers No No No No No No No ME H 788 2016 PBMs No No No No No No No MD 15-1628.1 2015 PBMs No No No No No No No MD 15-1628.1 2018 PBMs No No No No No No No MN 151.214 2017 PBMs No No No No No No No MT S 211 2015 PBMs No No No No No No No Manufacturers, PBMs, NV SB 539 2017 Insurers Yes Yes No No Yes No Yes NH HB 1418 2018 Manufacturers No No No No No No No NJ N.J.A.C. 11:4- 62 2017 PBMs No No No No No No No Manufacturer, OR H 4005 2018 Insurer No No No No Yes No Yes PA A 169 2016 PBMs No No No No No No No RI S 2467 2016 PBMs No No No No No No No SD S 118 2015 Insurers No No No No No No No TX H 1624 2015 Insurers No No No No No No No TX H 1227 2017 Insurers No No No No No No No Manufacturer, VT S 216 / A 165 2016 Insurer No No No No No No No © 2019 Ryan MS et al. JAMA Network Open. Manufacturers, Insurers, VT S 92/A 193 2018 PBMs Yes No No No No No Yes We classify each law as informative if it requires a supply chain participant (such as insurers, PBMs, manufacturers) to disclose either 1) rebate amount, 2) profit, or 3) net price. We base these criteria on research findings that rebates, profits and net prices are crucial to determining who is responsible for high drug costs and for examining the potential effects of policy proposals to control drug costs, including removing safe harbor protections for rebates, using external reference 1-5 pricing and eliminating spread pricing. To corroborate our approach, we asked a second analyst unfamiliar with our study to independently re-code our sample of laws using the same criteria. This second coding agreed with our original coding in 35 out of 35 cases. eReferences. 1. Wineinger NE, Zhang Y, Topol EJ. Trends in Prices of Popular Brand-Name Prescription Drugs in the United States. JAMA Network Open. 2019;2(5):e194791-e194791. 2. Sood N, Shih T, Van Nuys K, Goldman DP. Follow The Money: The Flow Of Funds In The Pharmaceutical Distribution System. Health Affairs Blog. 2017. https://www.healthaffairs.org/do/10.1377/hblog20170613.060557/full/. Accessed June 13, 3. Dusetzina SB, Conti RM, Yu NL, Bach PB. Association of Prescription Drug Price Rebates in Medicare Part D With Patient Out-of-Pocket and Federal Spending. JAMA Internal Medicine. 2017;177(8):1185-1188. 4. Council of Economic Advisers, Executive Office of the President. Reforming Biopharmaceutical Pricing at Home and Abroad. https://www.whitehouse.gov/wp- content/uploads/2017/11/CEA-Rx-White-Paper-Final2.pdf. Published February 9, 2018. Accessed July 1, 2019. 5. Senate Committee on Finance. Description of the Chairm Pricing Reduction Act (PDPRA) of 2019. https://www.finance.senate.gov/imo/media/doc/FINAL%20Description%20of%20the%20 Chairman's%20Mark%20for%20the%20Prescription%20Drug%20Pricing%20Reduction% 20Act%20of%202019.pdf. Published July 25, 2019. Accessed July 27, 2019. © 2019 Ryan MS et al. JAMA Network Open.

Journal

JAMA Network Open – American Medical Association

Published: Sep 25, 2019

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