Trends, Entrants, and Developments (TEDs) Impacting Access: Practices Payers Are Leveraging to Bend the Cost Curve

Good day to you. I am Elizabeth Oyekan, PharmD, FCSHP, CPHQ, Vice President – Access Experience Team, and editor of All Access Newsletter. Due to the significant financial losses by health systems over the last 18 months, and now health plans experiencing adverse impacts to their bottom line as patients come back in for care, these entities are looking for strategies to make up for these losses now and in the future.
In this edition of the All Access Newsletter, we have asked our key expert ex-payers to provide insights into evolving practices payers are leveraging to bend the cost curve.

  • Cynthia Miller, MD, MPH, FACP and Reta Mourad, PharmD discuss the importance of biosimilars in supporting the sustainability of the healthcare system by reducing costs of biological therapies through increased competition while maintaining the quality of care
  • Jennifer Williams, PharmD, BCOP reviews the top reasons payers are adopting clinical pathways and guidelines in the oncology space and the tumor types being targeted, as well as future possibilities payers are exploring in non-oncology specialties to further leverage pathways and guidelines
  • Todd Edgar, PharmD, MS takes us into the world of value-based contracting with new perspectives on how these contracts should be viewed, learnings from past years, and opportunities to make them a win-win for stakeholders
  • Kellie Rademacher, PharmD explores the complex world of biomarker testing including the several testing options available, the expansion of biomarkers, and the resulting challenges for various stakeholders. Kellie highlights possible policy recommendations to help payers and providers address existing challenges and support stakeholder efforts in their pursuit of precision medicine
  • Ryan Cox, RPh, MBA takes us into the world of accumulators and maximizers being used by pharmacy benefit managers (PBMs) and health plans as a result of a continued pressure between plan benefit design, the expansion of manufacturer copay programs, and the growth of drug spending. Ryan discusses what they are, how they work, and their impact on various stakeholders

We believe you will find these current and evolving payer practices to bend the cost curve in healthcare and their impact on access insightful as you navigate the payer landscape. As always, please feel free to drop me a note and let me know if you have a topic suggestion for the payer team to address, and we’ll do our best to cover it in a future edition.

Best regards,

Elizabeth Oyekan
PharmD, FCSHP, CPHQ
Vice President,
Access
Experience Team

EMAIL ELIZABETH

All Access is a bimonthly newsletter that features key insights from our team of former payers, intended specifically for market access leaders. It is published by PRECISIONvalue.

Guest Editor
Elizabeth Oyekan

Executive Editor
Louis Landon

Contributors
Andrew Cournoyer
Ryan Cox
Dan Danielson
Todd Edgar
Dominic Galante
Ami Gopalan
Maureen Hennessey
Joe Honcz
Louis Landon
Erin Lopata
Reta Mourad
Kellie Rademacher
Charline Shan

Practices Payers Are Leveraging to Bend the Cost Curve

How do biosimilars support the sustainability of the healthcare system? Cynthia Miller and Reta Mourad demonstrate how biosimilars reduce costs of biological therapies through increased competition, while also maintaining the quality of care.

Cell and Gene Therapy Circa 2021

Stay up to date on the innovative research in cell and gene therapy and the implications for disease treatment. Ray Roth reviews the benefits and risks of these therapies, the financing and partnerships occurring, and payer issues and tactics for supporting the reimbursement for cell and gene therapies.

Specialty pharmacy’s role in gene and cell therapies

What role do specialty pharmacies have in cell and gene therapies for payers, providers, manufacturers, and patients? Erin Lopata highlights the SP’s roles in partnership coordination between payers and manufacturers, the leveraging of data to support arrangements, and the focus on patient-care coordination and financial support to improve patient outcomes.

Leveraging Data and Analytics to Impact Access and Drug Costs

How are payers using the data and analytics becoming increasingly more available to them? Sejal Jonas explores how the effects of factors like deeper digging into trend drivers, developing financial models, and evaluating opportunities including partnerships being formed can leverage real-world data and evidence to optimize the decision-making process.

Policies and Politics—What’s in Store for Healthcare?

With Joe Biden’s inauguration as the 46th president of the United States and Democrat control of both the house and senate, there are a number of policy changes anticipated. As expected, the current focus of the administration is the pandemic, bolstering the roll-out of the vaccine and providing economic support to those parts of the economy that have been most impacted, but what else? Precision’s Ryan Cox explores some of the expected policy priorities and changes for healthcare in 2021.

M&A in 2020, Implications for 2021

New healthcare policies undoubtedly mean a shift in market access. In this article, Precision’s Dan Danielson explores the high-level potential market consequences in 2 major segments of the US healthcare environment and the rationale behind each: the healthcare systems and hospitals that deliver care, and pharmaceutical manufacturers who develop new drug therapies for the patients served by the health systems.

CMS Physician Fee Schedule (PFS) Creates More Tailwinds for Telehealth and New Opportunities for Pharma

Telehealth vendors, health systems, and clinicians are seeing opportunities to further expand delivery of reimbursable telehealth services since CMS issued its (CY) 2021 Medicare Physician Fee Scale final rule on December 1, 2020. Precision’s Maureen Hennessey discussing the impact of these expanded opportunities, and how they set the stage for amping up the velocity for telehealth growth.

What Healthcare Initiatives Will the Biden Administration Consider in 2021? A Regional Health Plan Perspective

With the COVID pandemic still firmly gripping the US, developing and implementing plans to address the crisis on “day one” is a top priority agenda item. But what else makes the list? Dan Danielson reviews the top 2 agenda items for the Biden Administration and the impact on regional health plans.

Will the Biden Administration Move the Needle Toward Improving Affordability? A National Health Plan Response

The inauguration of President-elect Biden will mark the end of a tumultuous 4-year run of the Trump Administration’s failed attempts to overturn the Affordable Care Act (ACA) and find a solution to meaningfully lower drug costs for all. Andrew Cournoyer examines how national health plans may react to Biden’s goal of affordability.

The GPO Spectra: Why ASCENT and ZINC Are the Defining PBM Story of 2020

Flying under the radar amid the chaos and uncertainty caused by COVID-19, a rather large change in the PBM market is occurring: the rise of rebate GPOs. Jeremy Schafer unpacks these changes and dives into the development of ASCENT and ZINC, and what they mean for manufacturers and contracting changes moving forward.