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.
PharmD, FCSHP, CPHQ
Access Experience Team
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.
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.
Explore the top reasons payers are adopting clinical pathways and guidelines in the oncology space. Jennifer Williams shares 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 shares new perspectives on value-based contracting on how these contracts should be viewed, learnings from past years, and opportunities to make them a win-win for stakeholders.
Kellie Rademacher explores the complex world of biomarker testing including the several testing options available, the expansion of biomarkers, and the resulting challenges for various stakeholders.
Stay up-to-date as Ryan Cox discusses how accumulators and maximizers are being used by PBMs and health plans in response to continued pressure between plan benefit design, the expansion of manufacturer copay programs, and the growth of drug spending.
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.
Rare and orphan drug therapies have had exponential growth in the last decade. Kellie Rademacher explores their costs and impact to payers and the overarching healthcare systems, as well as value-based agreements that are being explored to pay for these 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.
Trends Impacting Access: Cancer Care and Gene Therapies–Innovative Payment Models for High-Cost Therapies
Janet Serluco addresses trends impacting access in cancer care and the innovative payment models being considered to pay for these high-cost therapies, as well as the need to focus on value of therapies in the oncology and gene therapy space to support access and reimbursement.
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.
The virtual engagement world has become an absolute necessity in healthcare to engage and interact with different stakeholders. Reta Mourad takes us into that world by examining the challenges and opportunities experienced in this new virtual health environment.
Hetty Lima describes some of the latest trends in the world of technology and artificial intelligence that will possibly impact drug access, including streamlining the formulary decision-making process, optimizing precision medicine, and even potentially expediting drug approvals.
Health economics and outcomes research (HEOR) and health technology assessment (HTA) value frameworks have been gaining leverage. Dan Danielson walks us through how their impact is expanding, including their scope and evolving influence in healthcare and access.
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.
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.
With the new changes in the latest CMS 340B rules and policies regarding patient access to discounted drugs, there will certainly be challenges between pharma and contracted pharmacies. Precision’s Dominic Galante discusses the potential positions that will be taken by plaintiffs, and the associated 340B Program litigation.
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.
Following a tumultuous 2020, IDNs, like many other healthcare systems, are going to be impacted by several elements including an unprecedented number of current and proposed policies. Elizabeth Oyekan discusses 4 policies and regulations that we may see in 2021.
While campaigning, President-elect Biden laid out many proposals with respect to healthcare, most of which have in common the effect of expanding the Federal government’s role in this space. Todd Edgar explores how this expanded role will affect managing healthcare, and the effect it will have on PBMs.
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.
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.
Almost to the level of saturation, there have been a remarkably high number of articles and publications examining the impact of COVID-19 on the US healthcare system. Precision’s Ryan Cox takes a look at some of the less-mentioned trends hinting at changes coming to health systems in the near future.
How will the proliferation of specialty pharmacy products available in the marketplace be managed by payers? Precision’s Erin Lopata examines the larger role of specialty pharmacies in managing care and costs as payers work to find solutions to high pharmacy and medical spend in their specialty populations.
What are the key takeaways and approaches to delivering unique membership experiences and building loyalty to regional Medicare plans? Precision’s Dominic Galante examines how these plans will keep members engaged and enrolled, one of their top priorities, among the uncertainty caused by COVID-19.