Prescription Drug Affordability Boards (PDABs) are independent entities established to analyze the high cost of drugs and to identify effective ways to lower cost in order to increase access to affordable drugs for consumers.
Seven states have established PDABs: Colorado, Maine, Maryland, Minnesota, New Hampshire, Oregon, and Washington. The PDABs in Colorado, Maryland, Washington, and Minnesota have the authority to establish an upper payment limit for a drug that the PDAB deems unaffordable. In August 2023, Colorado’s PDAB completed its initial selection of five drugs that will be subject to affordability review and potentially upper payment limits.
NASHP spoke with Colorado’s Prescription Drug Affordability Director Lila Cummings about the Board’s trailblazing work to address prescription drug costs.1
What is the purpose of the Colorado Prescription Drug Affordability Board?
Lila Cummings: There is a legislative declaration in the PDAB statute that discusses the challenges faced by Coloradans in accessing prescription drugs, both generally and for specific communities. Patient health often suffers because high prescription drug prices make drugs inaccessible. The goal of the Board is to understand which prescription drugs might be unaffordable and to make them more affordable so that folks can access the prescription drugs that they need to live.
Colorado’s PDAB can set upper payment limits for prescription drugs that the board deems unaffordable through affordability review. What is the goal of an upper payment limit?
LC: An upper payment limit contributes to the overarching goal of making drugs more affordable so that they are more accessible. The goal of an upper payment limit is to establish a dollar amount that allows a drug to be accessed by more individuals. When the board sets their inaugural upper payment limits, we will discuss their specific goals for each drug’s upper payment limit. For example, is the upper payment limit intended to make the drug more affordable for the specific patient population that is accessing that drug? Is the upper payment limit intended to have an impact on premiums and make the drug more affordable that way? We know that prescription drug costs are one of the No. 1 drivers of premium increases across the state, so we know that everybody wins when drug costs are lower.
What has the board accomplished so far?
LC: One of the first things that the board did was choose 15 people out of 50 applicants to appoint to the Prescription Drug Affordability Advisory Council (PDAAC), which required careful consideration of which individuals and perspectives would best support the board. In 2022, the board hosted a five–part learning series, which included sessions on the pharmaceutical supply chain, prescription drug data, and prescription drug affordability efforts in other states. The board has promulgated five rules and adopted several policies to guide their work, notably for affordability review and the upper payment limit methodology. It was important to the board to craft guidance ensuring that any savings resulting from an upper payment limit are passed on to Coloradans before undertaking the upper payment limit process.
As of summer 2023, the board has gone from setting up their program to digging into the work. The board reviewed a massive amount of data housed on the Eligible Drug Dashboard, an interactive public dashboard of 604 drugs that qualified for affordability reviews. Using that list, the board then selected five drugs (Enbrel, Genvoya, Cosentyx, Stelara, and Trikafta) for affordability review. Two major considerations guided the board’s selection of drugs for affordability review: choosing drugs without a generic, therapeutic equivalent, or biosimilar and choosing drugs with high utilization.
The board has also clearly signaled how important the consumer voice is in their decision-making. The board has created many opportunities for stakeholders to engage and provide feedback. Stakeholders can contribute verbally at meetings to share their experiences. We also created surveys and accept any kind of written story, testimony, or information.
How does the board incorporate consumer and partner perspectives into its work?
LC: Colorado’s law stipulates that the board needs to consider input from consumers and caregivers, as well as input from individuals with scientific and medical training. The board has made public voice a formal part of their operations. As I mentioned, the board has an advisory council, the PDAAC, that ensures that we are getting advice from everybody along the entire supply chain and the entire continuum of care, from consumer to provider. The board also allows anyone to voluntarily submit information, and there are no restrictions on what sorts of entities can share information for the board to consider.
Further, the board has asked me and my staff to conduct as much stakeholder engagement as possible. We have tried to go above and beyond to create opportunities for stakeholders beyond the minimum requirements for engagement. The week after the board selected drugs, we created a stakeholder engagement guide that outlines some of the formal and more informal opportunities. Every time the board is going to promulgate rules at a rulemaking hearing, we try to hold multiple meetings ahead of time to answer questions about the process and collect expertise that can inform the board’s work. We also have multiple opportunities for public comment at nearly every board meeting,
We also have relationships with pharmaceutical companies, including the manufacturers of the five drugs selected for affordability review, and the Colorado Association of Biosciences. While we might not always agree, we have an open-door policy and communicate regularly. Looking forward, we want to do more to connect with the organizations and community members that represent the conditions that drugs selected by the board treat. We are actively working on how to engage these consumers, organizations, and associated providers so that they understand the process and so that we can create spaces and opportunities for them to help us understand their perspectives and experiences.
What does the work of Colorado’s PDAB look like moving forward?
LC: In the upcoming months, the board will review the affordability review summary reports and decide if there is evidence that a drug is not affordable. If the board deems a drug unaffordable, they will consider whether an upper payment limit is an appropriate next step. Setting an upper payment limit would involve rulemaking on a three-month timeline, and as that work is happening, the board will also be preparing for their second round of affordability reviews.
We are excited to move into our second year of affordability reviews with all the insight we have gained, particularly on the data side. We have learned how we can use our data in more effective and nuanced ways and will present these findings to the board soon.
Is there anything else you would like to add, especially for states that might be considering creating a PDAB?
LC: I want to acknowledge the great work of the Colorado Prescription Drug Affordability Board and Advisory Council. Doing this work for the first time is hard, but it’s exciting. I would also highlight that there is a strong national group from other PDAB states that NASHP convenes regularly to lean on each other and learn from each other. I think it’s important to know that there are others doing this important work and sharing insights with each other.
As Colorado’s board chair, Gail Mizner, said at the board’s October meeting, the thorough kind of analysis that PDAB implementation requires may generate suggestions for what else states can be doing on drug costs. This work on prescription drug pricing is igniting new policy ideas, and I’m excited to see what arises. If you are a state that wants to pursue or continue to pursue prescription drug affordability policy, I think PDABs are a way to shine the light on prescription drug cost challenges and potential policy solutions, both through PDABs and upper payment limits, but also beyond.
NASHP interviewed Cummings on November 2, 2023. 1. Cummings noted that she does not speak for the board and that her words reflect her experience and goals leading its support staff.
