The Kinetix Group (TKG), joined by the AMCP Annual Meeting, hosted its inaugural Managed Markets Insights Advisory Panel, moderated by Stanton Mehr, on March 27th in Denver. The panel featured eight payer and pharmacy leaders from national and regional health plans, health systems, and pharmacy management organizations. They provided strategic insights into today’s rapidly changing managed markets industry, discussing biosimilars, product access, risk sharing, value-based purchasing, patient engagement, market consolidation and the role of the pharmaceutical industry.
Below are key takeaways from their discussions.
Section 1: Biosimilars, Current and Future
Biosimilars, reviewed by P&T as if new drugs, are handled separately from reference products. Panelists discussed biosimilar legal review, including P&T, AntiTNFs (new versions and implications), and considerations beyond cost.
KEY TAKEAWAYS: Given tedious review processes and relatively insignificant cost differentials, especially in chronic care, payers usually prefer to cover existing products over biosimilars.
- WHAT OUR EXPERTS SAID: “When we talk to our physicians, we do not hear one concern about whether the biosimilar is effective; they all think they are effective, but the conversation is around cost.” – Large Payer Network, South Central
- WHAT PHARMA CAN DO: Companies now making biologics should maintain heightened credibility: the industry reputation of a drug and its manufacturer lead to strong payer and pharmacy biosimilars preferences. Payers and pharmacy leaders prefer consolidated contracts, so adding biosimilars into portfolios for better pricing on groups of drugs will drive adoption into treatment plans. Overall, pharma can enhance provider experience by increasing services that save physician time and support patient adherence.
Section 2: Product Access
Opportunities were outlined for expediting product access among select populations, such as blanket PA waivers for high-risk patients overseen by select MDs.
KEY TAKEAWAYS: With clear utilization guidelines and established criteria, PA allows managed care to control who prescribes specific drugs. However, when physicians own potential risks, waiving PAs offers more thorough reviews than those of health plans.
- WHAT OUR EXPERTS SAID: “It would be difficult to write the guidelines to waive the PA for some people and not for others.” – Large Payer Network, Midwest
- WHAT PHARMA CAN DO: Ensure streamlined, efficient PA to avoid burdening providers.
Section 3: Risk Sharing
Panelists discussed challenges in pharma-payer risk sharing, efficacy of total risk sharing contracts, and partnering opportunities with payers, health systems, and medical groups, apart from value-based agreements.
KEY TAKEAWAYS: Pivotal challenges in pharma-payer risk sharing include ambiguous data, uncertainty, past deals, and convincing drug companies and practices to sign risk-sharing agreements.
- WHAT OUR EXPERTS SAID: “In some ways we are captive by the FDA. Once a drug is approved by the FDA, even if it has little or no real value, it is hard to resist covering it.” – Large Payer Network, South Central
- WHAT PHARMA CAN DO: Value-add programs spawn work, but unbranded resources would be useful. Pharma should help develop patient identification screeners, successful in appropriately directing patients to providers. Pharma can segment growing Medicaid populations as a managed market neglected because of branded responsibility to CMS rebates.
Section 4: Value-Based Purchasing
Panelists addressed value-based purchasing utility in commercial health plan and insurer markets, as well as ACO successes driven by CMS’s increased value-based purchasing efforts.
KEY TAKEAWAYS: Value-based purchasing has scant appeal in commercial health plan and insurer markets as pharma usually offers low cost options showing little improvement. The CMS ACO push insufficiently promotes patient adhesion to health systems, making patient management difficult. Providers with no control of where patients receive care have little influence over services received.
- WHAT OUR EXPERTS SAID: “There are very few delivery system entities that can pull off this full integration of care, and these organizations only touch a very small minority of the American population.” – Large Payer Network, South Central
- WHAT PHARMA CAN DO: When working with ACOs, Pharma should consider who manages relationships between health plans, patients, and providers. Pharma can leverage health plan data to assist ACO success.
Section 5: Patient Engagement
Panelists discussed disease states galvanizing patient engagement, innovative strategies for improving engagement, and approaches to avoid.
KEY TAKEAWAYS: Symptomatic diseases (e.g., multiple sclerosis, cystic fibrosis, hemophilia, diabetes, HCV, and oncology) usually generate greater patient engagement. Patients bombarded with information from providers, employers, pharma, and TV ads now ignore mailed letters and phone calls. Urging too great an improvement at once leaves patients overwhelmed and less engaged.
- WHAT OUR EXPERTS SAID: “The challenge is: How do you engage the non-engaged? The patient has to want to do it. Those who participate often are the patients that are already engaged.” Integrated ACO, Southwest
- WHAT PHARMA CAN DO: Pharma’s most important next step is creating and targeting resources, such as incentive-based engagement activities, for non-engaged patients. Medication management campaigns at patients’ pharmacies have proved effective.
Section 6: Consolidation
Panelists shared ‘5-year’ predictions on health system marketplaces, care delivery consolidation and key trends.
KEY TAKEAWAYS: Consolidation will continue, with small physician-group viability tenuous, given EMR, quality metrics, and administrative changes. Among payers, large employer groups, commercial and concierge medicine, and patient-centered medical homes, consolidation will become prevalent.
- WHAT OUR EXPERTS SAID: “MIPs is the huge driver pushing small physician practices into closing or joining larger groups, because they will not be able to handle the increased administrative burden.” – Integrated ACO, Southwest
- WHAT PHARMA CAN DO: Create data-based, population health programs. Above marketing and sales efforts, target building health department infrastructures that provide and improve care.