"When it comes to Healthcare ....Pricing is what you pay....Value is what you don't get."
—Mashup with Warren Buffet and Yogi Berra
One of the most important factors in investing in healthcare going forward is truly understanding and accurately forecasting the potential earnings power of new products and services. The ability of investors to accurately determine the future prices of new products and services is absolutely critical towards accurately modeling the EBITDA, ROI, EPS, CAPEX and NPV of the companies they are targeting.
The rewards of correctly calculating these factors over time can be wonderfully life-changing in terms of one’s portfolio. The cost of miscalculating these factors over time can be equally as devastating.
At the recent Harvard Business School Healthcare Alumni Conference, it was estimated that in the coming decade more than $10 trillion in wealth will be created as investors are drawn to new innovative healthcare products and services. Innovation in healthcare has blossomed with the science behind the Genomic Revolution and the realization that many human illnesses, particularly cancer, are analogous to software defect. Precision medicine and other new forms of treatment based on discoveries in molecular biology and computer science promise to revolutionize the way we care for patients.
However as rosy as this outlook appears, it was also predicted at Harvard that more than $4 trillion will be destroyed during the same time period. This will be the result of products and services made obsolete by these new disruptive discoveries at a pace never before seen.
To state the obvious, in order to create Alpha, investors will need to put their money on the winners and short or avoid the losers. A key determinant to winning will be the mastery of Pricing.
Why Pricing Matters
In the United States, the process by which the pricing of new products and services in healthcare occurs is a function of the regulatory environment that controls the pace of innovation and competition--both of which are a byproduct of complex state and federal political processes that regulate the healthcare industry. In the past, predicting pricing on future products and services was relatively easy because there was no requirement to take into the account the “clinical value” of the product or service produced. If the product was new or competition could be held to a minimum, forecasting pricing for investors could be rather straight forward with fairly predictable and steady results and cash flows
Over the last year or so, an increasing number of critical headlines have appeared regarding the way drug prices are established in the United States. This is not really surprising as many business models are dependent on some form of price and quality opacity for a significant portion of their profits. The only real surprise to this observer is that it's taken so long for this issue to appear on the front burner.
As a Healthcare investor, one cannot have failed to notice the almost daily stories regarding the pricing of innovative new medicines such as drugs to treat hepatitis C as well as stories about companies purchasing older medications and raising their prices dramatically. The former discussion really is about how society wants to reward the risks and cost of innovation going forward. The latter is about how much society wants to permit competition and the information transparency required to enable it.
Understanding the Future of Innovation and Competition
There is a disruptive revolution going on in the areas of innovation and competition. The disruption caused by Innovation is being driven by the scientific discoveries we previously mentioned.
The disruption occurring in Competition is being caused by legislation, the unsustainable increase in healthcare spending as a percentage of GDP, and the revolution in technology that is empowering consumers.
As a result, it is critical for investors to have a point of view on both of these factors. The days when new drugs can simply be priced without limitation is coming to an end. Emerging discussions focused on pricing new innovations by simply using “cost accounting” to develop new drugs ignores the extraordinary risks that financial capital is required to endure to produce them. Current estimates are that nine out of 10 drugs fail to reach the marketplace. While it is often mentioned that it can cost more than $1 billion to get a new drug to market, what investors often to fail to realize is that the costs often refers to nine drugs that failed at $100 million each as well as the one drug that succeeded for $100 million. Simply pricing the new drug based on its $100 million cost of development while ignoring the losses investors suffered will dramatically reduce the incentives for innovation. While I expect these cost-based discussions will receive a lot of attention and will need to be closely monitored to see if they get real traction, I don’t believe they will be enacted. Having personally experienced the failure of wage and price controls in the early 1970s, I don't believe that our society will go back in that direction.
If we are to motivate investors who are expected to endure nine total investment failures for every success, society will need to balance the enormous investments required to produce new drugs with their attendant risk of failure against the potential value that new inventions bring to society. The nascent move towards pricing new medications based on the value they bring to patients and society is one that I believe every investor is going to need to come to grips with because slowly, but inevitably, I believe it will become the coin of the realm.
At the same time the use of competition to help moderate and establish drug prices will increasingly come to fruition as a policy tool and as an outcome of the consumer revolution. As consumers become responsible for paying for a larger percentage of their drug costs out of the their own wallets through a combination of increasing copayments, deductibles, tiered pricing arrangements and indication-specific pricing, we can expect consumers and those entities that negotiate for them such as pharmacy benefit managers, health plans and consumer focused ecommerce websites to continue to revolutionize the purchasing process in the same way that consumer empowerment has revolutionized the travel industry, the retail industry and the transportation industry.
How Politics as Usual Affects Drug Pricing
It should be no surprise that the healthcare industry will push back on competitive forces where it can through mergers and acquisitions, advertising as well as intense lobbying to help move the political process in its favor. Just look at the way Airbnb and Uber have mobilized its customers to act in the political arena to defeat political actions designed to limit their business. I believe the health industry will continue to raise prices on older products as it can, albeit more discreetly, both to boost cash flow for investors as well as to fund development of new innovations. I also expect the government to apply more scrutiny to transactions that reduce competition. The Federal Trade Commission already appears to be taking a more active stance with respect to mergers in the healthcare provider space.
As these forces of innovation and competition continue to disrupt the healthcare system, it will be more important than ever to understand how these forces will impact the pricing of the new products or services being considered for capital allocation. This is because the major driver of future wealth creation will be both the creation of new products and services AND the ability to set a price for them that rewards investment.
While stories about order of magnitude price increases for older drugs may make for interesting headlines in the short run, the days of unbridled price increases for drugs and services that are unrelated to the clinical value being created are clearly coming to an end. Business models built on this strategy of “buy and raise” are no longer as attractive to investors as they once were.
Investing in an Evolving Healthcare Market
In the future, investors will create Alpha through their focus on competition and innovation and understanding their impact on pricing. This focus will likely lead to three types of investment situations:
1. Products and services that are truly innovative and can produce superb clinical outcomes and have no meaningful clinical competition. These companies will command well-deserved premium pricing that will result in outstanding returns for shareholders.
2. Products and services that are made obsolete by innovation. These companies will rapidly lose pricing power with dismal returns for their shareholders.
3. Products and services that have traditionally relied on quality and information opacity or reduced competition. Without a truly innovative competitor, these companies will slowly lose pricing power until they are either obsoleted by an eventual innovator or find a stable price point that provides reasonable value for the clinical outcomes obtained. Such a scenario, which will likely be the most common of the three, will yield slightly below market matching returns for their shareholders.
In order to create Alpha, your healthcare portfolio will need to find and invest in several category one’s in order to compensate for the inevitable category three’s while avoiding category two’s at all costs.
The health investing game is clearly becoming more difficult, potentially more lucrative and a lot more risky. An understanding of the forces that shape pricing will be required for all who wish to play going forward.
By Dr. David Friend, MD, MBA, the Chief Transformation Officer and Managing Director of BDO’s Center for Healthcare Excellence & Innovation.
DISCLOSURE: The views and opinions expressed in this article are those of the authors, and do not represent the views of equities.com. Readers should not consider statements made by the author as formal recommendations and should consult their financial advisor before making any investment decisions. To read our full disclosure, please go to: http://www.equities.com/disclaimer