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.
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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.
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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.
Explore the increasing level of influence IDNs have over drug therapy prescribing and what tools they are leveraging to manage drug costs and spend.
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 address the rising cost of drugs employ both offensive and defensive tactics; which ones are making the biggest difference?
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Explore the the world of digital therapeutics as Joe Honcz discusses how they differ from wearables, as well as challenges around coverage and access with the increase in demand and use.
How can stakeholders across the healthcare system look to value-based care models to improve healthcare outcomes and quality while decreasing overall costs? Erin Lopata highlights 5 significant trends that manufacturers can partner with payers and health systems on in their quest for value-based care.
What are employers various roles in promoting and improving the quality of care? Jorge Font explores how life science organizations can engage and support employers to raise their understanding of the value of certain therapeutic approaches aligned with the employers’ quest to improve quality and care for consumers.
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.