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
The new Equity Measures in HEDIS 2022
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FDA Under New Leadership: Future Direction
In February 2022, Robert M. Califf was confirmed as the FDA Commissioner for the second time. A seasoned physician and leader who is late in his career, one can expect that his term will be impactful and influential. Advancements in medicine have required a faster approval process from the FDA while at the same time taxing payers financially and demanding robust evidence from manufacturers.
Future of Gene Therapy Reimbursement Models
Gene therapies bring the prospect of cures once unimaginable. The potential is exciting, but we cannot assume today's healthcare system can accommodate the financial burden expected from the gene therapy pipeline. Innovative therapies come with high manufacturing and delivery costs and target low patient numbers leading to million-dollar price points.
Medicare Advantage Outpaces Traditional Fee-for-Service (FFS) Enrollment: Implications
On June 15, 2022, the Supreme Court of the United States (SCOTUS) ruled in favor of hospitals over Medicare regarding a 340B reimbursement policy instituted in 2018 and unanimously decided that the almost 30% in cuts to Medicare outpatient drug payments for hospitals participating in the 340B drug pricing program was unlawful.
340B: Implications of the New Ruling
On June 15, 2022, the Supreme Court of the United States (SCOTUS) ruled in favor of hospitals over Medicare regarding a 340B reimbursement policy instituted in 2018 and unanimously decided that the almost 30% in cuts to Medicare outpatient drug payments for hospitals participating in the 340B drug pricing program was unlawful.
The Next Steps in the Oncology Care Model (OCM) – Potential Implications and Opportunities
The OCM was a 5-year voluntary advanced payment model that the Centers for Medicare and Medicaid Services (CMS) developed through the Innovation Center (CMMI) beginning July 1, 2016. CMS changes to advanced payment models due to the COVID-19 Public Health Emergency turned it into a 6-year model, which ended June 30, 2022.
Climate, Taxes, and Price Controls – What’s In the Inflation Reduction Act
President Biden signed the Inflation Reduction Act (IRA) into law on August 16th. The law includes new spending on climate initiatives, new taxes and enforcement, and drug pricing controls include significant changes to the Medicare Part D benefit. On the surface, measures to address drug pricing has had broad bipartisan support; however, the implications from this law may have unintended consequences to the Part D beneficiaries, payers, as well as to drug development and innovation for years.
Ramping Up SDOH Quality Measures within Value-Based Reimbursement Roadmaps
The Centers for Medicare & Medicaid Services (CMS) recognize that health care spending rises as a percent of gross domestic product (GDP) yearly while also underperforming on quality and equity. In this article we will review current and emerging initiatives including new and proposed SDOH quality measures and activities linked to plan and provider payments and incentives, discuss barriers to success, and propose win-win solutions for pharmaceutical companies to advance these initiatives.
The Evolving Pharmacy Benefit Manager (PBM) Landscape
Dive into the evolving PBM landscape as Sejal explores tactics to bring new DUM tools to the market to effectively manage drug costs and spend.
DUM and the Integrated Delivery Network (IDN) Landscape
Explore the increasing level of influence IDNs have over drug therapy prescribing and what tools they are leveraging to manage drug costs and spend.
The Unintended Consequences of DUM Programs
DUMs are an important cost savings tool, but the administrative burden can be high. What are some strategies that can be employed to mitigate that burden?
CMS’s Current and Proposed Actions to Bend the Prescription Drug Cost Curve
CMS's current and proposed actions to address the rising cost of drugs employ both offensive and defensive tactics; which ones are making the biggest difference?
Employers and Benefits Consultants Assess Gene Therapy Costs and Solutions
Employer concerns are increasing in response to the rising number of "seven-figure costs" associated with emerging gene therapies. What does the future hold for employer coverage of advanced therapies?
Virtual-First Health Plans: Will These Plans Accelerate the Use of Telemedicine and Prevent its Decline While Lowering the Cost of Care?
Dive into Virtual-First Health Plans with Jennifer Williams as she explains how these entrants seek to leverage the virtual space to improve patient outcomes and enhance the patient experience, while simultaneously lowering the cost of care.
The Emerging Role of Community Pharmacists Along the Drug Use Continuum in Oncology
What role do community pharmacists have along the drug use continuum in oncology? Erin Lopata explores their involvement in addressing social determinants of health issues and supporting patients with adverse events.
Payviders: The Evolution of the Convergence of Payers and Providers and the Future of Healthcare
Examine the evolving world of payviders, including the evolution of the convergence of payers and providers in the future of healthcare, with Dominic Galante.
The Emerging Roles of Alternative Drug Makers—Will They Be Able to Disrupt the Drug Pricing Landscape and Impact Drug Costs?
Dig into the developing role of alternative drug makers and their impact on the drug pricing landscape with Barbara Henry.
Drug Policy Disruptors: March 2022 Roundup
Stay up-to-date on current and upcoming disruptive policies impacting the managed care landscape and explore their potential impacts on healthcare stakeholders with Reta Mourad.
Potential Oncology Price Wars from Across the Ocean?
What are the implications of China becoming a hot spot for oncology drug development for the US? Explore this competitive landscape with Jennifer Williams as she reveals the potential for a price war and the possible effects.
The Evolution of Biomarkers and Germline Testing in Therapy Selection and Disease Management
How has the use of biomarkers and germline testing evolved in therapy selection and disease management? Erin Lopata explains this advancement, as well as opportunities leveraging modeling, digital technology, and artificial intelligence, in the identification of targetable mutations in oncology and beyond.
The Impact of the Build Back Better Act Price Negotiations on Commercial and Medicare Drug Access
Stay up to date on the implications of President Biden’s new Build Back Better Act (BBBA). Ryan Cox takes us through the act's provisions to address drug spending by the federal government and private payers, as well as the impact on Medicare Drug Access.
COVID-19 and the New Chronic Disease
Explore the emergence of long-term COVID, as well as new strategies for health care stakeholders to help pivot to deal with this new phenomenon, with Cynthia Miller.
Can Real-world Evidence from Database Research Shape Therapy Choices?
Dive into the use of data analytics and real-world evidence in supporting therapy choices for patients with Dan Danielson as he highlights some of the emerging tools being used.
Quality Payment Program (QPP) – Emerging Trends With CMS Alternative Payment Models (APMs)
Dive into the world of the Quality Payment Program (QPP) as Dominic Galante reintroduces us to the purpose behind the shift from volume to value, the laws that have catalyzed this shift, and the resultant APMs.
2022 QPP Proposed Quality Measures and Improvement Activities: New Opportunities for Value-Based Alliances and Collaborations
Stay up to date on the changes to the 2022 QPP proposed quality measures and improvement activities with an overview from Maureen Hennessey, as well as suggested landscape analysis and customer partnership opportunities for pharmaceutical manufacturers in the quality and clinical improvement areas.