Our experts from McCann Health Managed Markets and Mosaic share their perspectives on the evolving payer landscape, trends and how pharmaceutical companies can adapt their strategies to align with changing payer priorities.
Payer strategies and technology/AI
Christine Castiglione, Director, Strategic Planning, McCann Health Managed Markets
Payers continuously look for ways to create efficiencies when it comes to leveraging the robust amount of data they have available. Artificial intelligence (AI) is increasingly playing a role in the way payers access, mine and use patient data to make decisions about therapies, identify and stratify populations to provide more targeted interventions and identify trends and opportunities to improve overall health outcomes.
Payers are also using AI’s advanced capabilities to effectively sift through patient claims, pharmacy data and hospitalization data to make more informed decisions regarding drug coverage and utilization management. AI is also giving payers the ability to enhance and leverage predictive analytics when designing their benefit structure, especially for employer and client accounts.
With the exciting innovation and untapped opportunities AI brings to the healthcare industry, there are concerns around how to provide the checks and balances necessary to ensure the accuracy of AI and the ability to monitor and correct for errors. This presents unique opportunities for manufacturers to play a role in influencing payer strategies with respect to AI and technology applications. Manufacturers can help guide payer use of AI and identify gaps and opportunities for assessing the potential impact drugs have on their population. Additionally, AI can be used to target at-risk patients and power population health initiatives.
It will be up to pharmaceutical companies to demonstrate the value of AI in this capacity and bring data to payers around patient identification, access challenges and opportunities for value-based arrangements. AI continues to evolve and will fuel innovation within the US healthcare ecosystem, and it will be up to all of us to identify ways to harness the power of AI and collaborate with payers to enhance patient access, affordability and improve overall outcomes.
Effectively communicating the value of pharma products to payers for formulary inclusion
Reta Mourad, PharmD, Strategic Planning Director, Mosaic
As the pharmaceutical landscape continues to evolve, payers are hyper focused on managing cost of care due to exploding pipelines, rising drug costs and policy changes. Manufacturers must ensure market access strategies account for these challenges that payers continue to face. In an increasingly competitive and cost-conscious environment, payers remain interested in the clinical value of a product yet seek improved benefits to overall healthcare spending and patient outcomes.
Payer value communications should be tailored and leverage a multifaceted approach that includes the following strategic considerations:
1. Highlight economic and real-world value
Payers are concerned with short and long-term impacts to their budgets, making it essential for manufacturers to provide robust health economic data. Cost-effective analyses, budget impact models and real-world evidence demonstrating meaningful cost offsets are critical. If a product increases costs but offers significant improvements in outcomes or addresses an unmet need, this value must be clearly and concisely communicated to show that cost of coverage outweighs the economic impact.
2. Consider value-based approaches
Payers continue to seek value-based contracting and payment models particularly when evaluating coverage for high-cost or high-impact drugs. Payers seek models that tie payment to clinically meaningful outcomes, thereby reducing their financial risk. Manufacturers should explore unique models that align with payer goals while ensuring access to effective therapies.
3. Emphasize equity and access
Addressing healthcare disparities is increasingly important to payers who are looking for products that improve access for underserved populations. Manufacturers can demonstrate added product value by demonstrating how their product addresses an unmet medical need or improves outcomes in vulnerable patient populations.
By combining these strategies, manufacturers can develop a compelling value proposition for their product that aligns with payer priorities and positions their product as a solution to the clinical and economic challenges faced in healthcare.
Cost pressures and considerations for pharmaceutical companies
Zachary Solomon, Creative Director, Copy, Mosaic
Over the past year, payers have faced a sharp increase in cost pressures based on the recent FDA approvals of products with high budget impact – either because of price or population size. While by no means a new trend, this cost pressure has become even more prominent for payers, with the impact of classes like the GLP-1s for type 2 diabetes and obesity as well as cell and gene therapies (CGTs) being cited across numerous sessions at this spring’s AMCP conference. These cost drivers have led to several evolutions in payer management that pharmaceutical companies need to consider:
1. Increased utilization management in rare disease and oncology: Manufacturers in these spaces will need to prove a higher level of value and minimal cost impact, and will likely see restrictions more closely aligned to clinical trial design than in the past. As a result, trial design during the development phase should take into consideration the targeted access goals.
2. A “spill-over” effect in other disease states: Payers may increase their scrutiny across the board to find cost savings that offset the increased expenses in new classes. Even manufacturers of products in unrelated categories need to consider these cost pressures, which may lead to an enhanced focus on demonstrating value and cost offsets.
3. Increased usage of value-based contracting: With the field of CGTs continuing to evolve based on new product launches, evolution of value-based contracts could provide learnings for launches of CGT and non-CGT treatments alike, as payers and manufacturers increase their level of sophistication regarding the implementation of these agreements. Manufacturers should continue to monitor this trend to understand new ways to partner with payers.
Navigating these new and heightened cost pressures will be critical to gain or maintain favorable access and ensure patients can receive the treatments they need.
To learn more, turn to McCann Health Managed Markets and Mosaic.
