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Market Access 101: Connecting Access Challenges to Brand Opportunities

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Last week, our payer marketing team hosted their inaugural All Access Festival event in our NJ headquarters. This rock concert-inspired event gave our colleagues an inside look at fundamental elements of optimizing market access strategies. Take a look at the presentation chock-full of insights from this event.

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Market Access 101: Connecting Access Challenges to Brand Opportunities

  1. 1. 2 WHAT is market access and WHY does it matter to your brand? WHO are market access stakeholders? HOW do these stakeholders control access and influence prescriber and patient behavior? HOW do manufacturers work to optimize market access? Today is all about answering these fundamental questions
  2. 2. WHAT IS MARKET ACCESS
  3. 3. 4 The ability for all appropriate patients to access a given product quickly, conveniently, and affordably. In the world of pharma, market access refers to:
  4. 4. 5 The ability for all appropriate patients to access a given product quickly, conveniently, and affordably. In the world of pharma, market access refers to:
  5. 5. 6 The ability for all appropriate patients to access a given product quickly, conveniently, and affordably. In the world of pharma, market access refers to:
  6. 6. 7 The ability for all appropriate patients to access a given product quickly, conveniently, and affordably. In the world of pharma, market access refers to:
  7. 7. 8 The ability for all appropriate patients to access a given product quickly, conveniently, and affordably. In the world of pharma, market access refers to:
  8. 8. Market access stakeholders hold the keys to product access for prescribers and patients MARKET ACCESS STAKEHOLDERS MARKET ACCESS STAKEHOLDERS If prescribers and patients can’t get access to the product, then the most innovative and creative professional, scientific, and consumer marketing campaigns won’t achieve their full commercial potential.
  9. 9. The 3 Ps: Payers, Population health managers, and Pharmacy managers/suppliers Organization type A.K.A. A-list members Why they do what they do Payers Commercial Health Insurance Companies Aetna Cigna UnitedHealthcare Contain costs (payments for covered products and services) Ensure appropriate utilization of covered products and services Self-Insured Employers IBM Microsoft Government-Sponsored Health Plans Medicare Medicaid Veterans Affairs Tricare
  10. 10. The 3 Ps: Payers, Population health managers, and Pharmacy managers/suppliers Organization type A.K.A. A-list members Why they do what they do Population Health Managers Health Systems Kaiser Permanente UC Health New York-Presbyterian Cleveland Clinic Health System Deliver high-quality care that improves patient outcomes Contain costs (personnel, drugs and other supplies, technology, etc) and maximize reimbursement Integrated Delivery Networks (IDNs)
  11. 11. The 3 Ps: Payers, Population health managers, and Pharmacy managers/suppliers Organization type A.K.A. A-list members Why they do what they do Pharmacy Managers/ Suppliers Pharmacy Benefits Managers (PBMs) Express Scripts CVS Health AllianceRx Walgreens Prime McKesson US Bioservices Contain drug costs and ensure appropriate utilization of formulary and nonformulary products Specialty Pharmacies (SPs) Efficiently deliver products with complex requirements or for rare diseases, and provide services to optimize therapy outcomes Group Purchasing Organizations (GPOs) Vizient Premier HealthTrust Intalere Help health systems, IDNs, and providers contain drug costs and run more efficiently There is considerable overlap among categories—for instance, some IDNs include payer and pharmacy components, and several of the big payers also operate their own PBMs.
  12. 12. 14 The top players at the 3 Ps Responsible for cost and quality of healthcare Weighs medical savings vs. pharmaceutical costs Reports to Medical Director Managed pharmacy benefit/budget Liaison to P&T Committee Manages PBM relationship Responsible for population- based quality NCQA accreditation/HEDIS Disease management Responsible for employer- and member-level sales and retention Wants high quality and low rates
  13. 13. 15 P&T committees: the formulary decision makers Health plans, health systems, hospitals, Veterans Affairs, and the military all have Pharmacy and Therapeutics (P&T) Committees Promote safe, efficacious, and cost- effective drug therapy by developing policies on drug evaluation, selection, and utilization Manage the development and continuing maintenance of the formulary Members mainly include medical director, pharmacy director, physicians (including specialists), and pharmacists; other members may include be nurses, nutritionists, administrators, and quality directors
  14. 14. Health plan formularies: the first line of defense for controlling drug costs Tier 1 Tier 2 Tier 3 Tier 4/5 Generics “Preferred” Brands “Non-Preferred” Brands Specialty Brands But, in this venue the “cheap” seats are costly. Client Goal: To get their brand on formulary at Tier 2 or “Preferred”
  15. 15. Tiered co-pay plans: drive generics, formulary compliance, and maximize manufacturer rebates Multi-tier co-pay design Possible therapeutic category Generic co-pay Preferred brand co-pay Non-preferred brand co-pay Lowest (Level 1) Diabetes $7.50 $15 $35 Medium (Level 2) Statins $15 $40 $60 Higher (Level 3) PPIs $15 $60 $120 Highest (Level 4) Specialty 25% (Max $50) 25% (Max $200) 40% (Max $400) PPIs = proton-pump-inhibitors.
  16. 16. Class- and drug-level restrictions and limitations: controlling the who, when, and where Prior authorizations (PAs) Product A will not be covered and reimbursed unless the HCP sends the health plan a form specifying certain key criteria (eg, diagnosis) Step edits/Step therapy (SEs) Members must first try Product A before trying Products B and C Quantity limits (QLs) Product A will only be covered for 30 pills for a 30-day period; another example is 6 months of therapy Provider-specific restrictions Health Plan A will cover only prescriptions for Product B written by a specific type of specialist (eg, urologist or enocrinologist)
  17. 17. The spectrum of payer management strategies Restrictive Prescribing Strict PA Step TherapyMild PA Quantity Limits Plan Spending Caps Tiered/ Co-pay Drug Utilization Review Basic Formulary Controls (less to more restrictive) $ $ $$ $ $ Financial Control Clinical Control Tighter restrictions don’t necessarily mean control of product choice; goal may be: • Appropriate use of treatment • Implementation of treatment algorithm • Proper diagnosis • Monitor patient/disease management
  18. 18. What’s so special about specialty drugs? •Specialty drugs include –Biotechnology products –Orphan drugs to treat rare diseases –High-cost drugs (>$300 per Rx) –Injectables and drugs that must be administered by HCPs –Drugs requiring high-touch patient services (education, follow-up calls, adherence support) •These drugs are typically Tier 4 (or even 5) and require patients to pay coinsurance (a percentage of the cost)
  19. 19. What’s so special about specialty drugs? They are on the rise! 20 years ago there were very few on the market, most were covered by medical benefits, and they accounted for only 7% to 10% of per member/ per year payer costs. Today, more orphan drugs are approved each year, payers are shifting coverage to pharmacy benefits (where patients share more costs), and they now account for about 40% of payers’ pharmacy budgets. The bottom line: specialty products are complex and are an area of focus.
  20. 20. MARKET ACCESS?
  21. 21. Contracting: edging out the competition •Under some circumstances, such as a crowded market, education may not be enough to gain favorable access •In these cases, drug manufacturers often negotiate contracts with payers, PBMs, GPOs, and even some IDNs to gain market share •As part of the contract, –The health plan or PBM places a branded product on Tier 2, making it a preferred brand –The manufacturer returns a (predetermined) percentage of the money the organization spent for the product if the designated market share is met In addition to volume-based contracting, the drive toward greater value in healthcare is giving rise to value- or outcomes-based contracting, in which reimbursement is tied directly to patient outcomes.
  22. 22. Educating and detailing to market access stakeholders: making the case for value Informed market access stakeholders who understand the value of the product are more likely to make favorable decisions and policies •Key topics for market access tactics –Disease state education –Product information •Clinical trial data, MoA, dosing, ordering, storage, price –Health economics and outcomes research (HEOR) data –Real-world data The core tactic for the Market Access audience is the Value Proposition—usually a presentation, sometimes with a leave-behind component—that covers most or all of the topics above.
  23. 23. Access & reimbursement support programs: building a safety net •“Hub” services—insurance, financial –Investigate the patient’s insurance benefits –Support for prior authorizations, appeals –Co-pay assistance programs –Referrals to other sources of financial assistance for patients who don’t qualify for co-pay assistance In many therapeutic areas, Hub and patient support programs are becoming the norm. Manufacturers have to work harder to distinguish their programs. •Patient support—education, adherence –Telephone hotline to speak with a nurse/pharmacist –Outbound calls to check in with patient –Adherence tools/support
  24. 24. Pull-through pays it off •Between education/detailing, contracting, and access support programs, manufacturers are investing significant funds and resources to ensure favorable access to their products •But low awareness of coverage and support programs can result in perceived barriers that keep HCPs from prescribing and/or keep patients from filling prescriptions •The pressure is on the sales force and brand teams to ensure that HCPs and patients get the message about the access that exists –Communicate access wins with major health plans –Generate awareness of available support services –Identify access problems as they occur at the regional or institutional level, and engage the appropriate mechanisms to address these problems
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