Health

Max Nisen is a Bloomberg Gadfly columnist covering biotech, pharma and health care. He previously wrote about management and corporate strategy for Quartz and Business Insider.

Zepatier is not a mononymous Latin pop star, an extra Musketeer, a soccer player, or a mysterious revolutionary. 

Price War!
Gilead investors aren't thrilled about pressure on its blockbuster hepatitis franchise.
Source: Bloomberg
Intraday times are displayed in ET.

Instead, it's Merck's new entrant into a now-crowded market of drugs that cure Hepatitis C, approved by the FDA Thursday night. And it's by far the cheapest, priced at $54,600 for a 12-week course. That's about a 42 percent discount to market leader Gilead's $13 billion-a-year blockbuster Harvoni and a slightly smaller discount to AbbVie's Viekira Pak.

Undercutting rivals on price is an unusual and stealthily brilliant strategy from Merck. It will likely burnish the company's image at a time when politicians are aggressively attacking high drug prices. It could possibly reshape the way drugs are priced. And who doesn't like a good old-fashioned price war?

Not Gilead shareholders. The company's shares were down 4.8 percent Friday on Merck's approval and price announcement, AbbVie's only slightly less. Merck was up 1.5 percent.

Drugmakers rarely price a branded drug like this so far below competitors, even when it's late to market. That's because list prices -- for all the furor they provoke as they push into the high five and six figures -- aren't what anyone actually pays for a drug. Insurers and pharmacy benefit managers negotiate big rebates. In the U.S., government programs such as Medicaid get significant mandatory rebates. 

Drugmakers tend to start high and quietly negotiate down from there. It's why Viekira Pak -- which makes patients take multiple pills and is less convenient than Gilead's one-pill option -- priced at only a narrow discount to Harvoni when it hit the market in late 2014. It's sort of an unspoken gentleman's agreement: Until generic competition comes along, companies price similar drugs in a similar -- usually high -- range, giving them a bigger pie to split. 

The prices actually paid in the U.S. for Gilead and AbbVie's drugs aren't too far from Zepatier's list price, once you consider the big discounts. But Merck changed the game by including assumed discounts in Zepatier's list price from the start. Had it priced higher, it still would have had to cut prices privately. By cutting them publicly, it embarrasses its rivals, making them look greedy, among other benefits. 

Merck may have been forced to compete on price. Zepatier was approved for a narrower set of HCV patients; it is not as effective across different subsets of the disease as Harvoni is. It also has stricter warnings for doctors prescribing it compared to its rivals, due to side effects. But Merck's price cut is pretty extreme; after mandatory and negotiated discounts, Zepatier will sell at a price well below the discounted costs of Gilead and AbbVie's drugs, creating significant price pressure. 

Volume may help Merck make up what it loses on price. AbbVie and Gilead's drugs are priced so high that many governments and insurers will only pay for them for patients that have severe liver scarring, given HCV's slow progression. Zepatier is priced at a point that could make it affordable to treat a much larger population at earlier stages of the disease. 

Gilead, with more than $18 billion in HCV drug sales in 2015, is easily the leader in this field, according to analyst estimates. In contrast, Zepatier sales are expected to be just $1.5 billion in 2017. That consensus doesn't factor in Merck's pricing and was generated before the drug's approval. Zepatier might snag higher market share than the chart below suggests. But Gilead is still expected to have the HCV drugs of choice, even as it faces downward price pressure.

Top of the Mountain
Gilead's hepatitis C revenue has likely peaked
Source: Bloomberg
AbbVie reported FY 2015 results, Gilead's number for the year is a consensus estimate

Still, by going with such a low list price for Zepatier, Merck effectively inoculates itself against the price criticism that has been leveled at the industry. Gilead in particular has been excoriated for pricing its HCV drugs so high.

HCV affects a large population compared to the diseases most expensive drugs treat, and it tends to affect less-wealthy people. By making its HCV drug cheap enough that it may expand access to more people suffering from HCV, Merck is doing something that genuinely benefits public health. 

When pricing its HCV drugs, Gilead did what most rivals would have done with a breakthrough drug facing looming competition: It priced as high as possible to maximize revenue while it was alone on the market. That provoked a Senate investigation, which put the company's unflattering internal pricing deliberations in the public domain. 

Merck's now the good guy in comparison. Other companies will likely be called to follow its example.

The impact of Merck's move on drug pricing more broadly may be limited. HCV drugs are cures. That means there's a finite number of patients to treat, and a race to get to them all, making price wars more likely. Chronic conditions such as arthritis, on the other hand, are treated for many years. The longer prices for drugs treating such conditions stay high, the more drugmakers benefit.  

But if Merck both wins in the court of public opinion and manages to snatch decent market share with its move, then there may be more price battles in the future.

This column does not necessarily reflect the opinion of Bloomberg LP and its owners.

To contact the author of this story:
Max Nisen in New York at mnisen@bloomberg.net

To contact the editor responsible for this story:
Mark Gongloff at mgongloff1@bloomberg.net