Managed Care Market Strategies 2014 Session Highlights

This week, The American Journal of Managed Care is covering CBI's 7th Summit on Managed Care Market Strategies taking place in Philadelphia, PA. The event includes stakeholder perspectives on improving market access and product value propositions in the evolving healthcare landscape. We continue to spotlight session highlights:

Optimizing Specialty Pharma Product Access and Reimbursement Support Services

Jeffrey Albright, director national accounts, Jazz Pharmaceuticals, said that many patients’ access to specialty pharmaceutical products—which treat serious or life-threatening illnesses—can be limited as health plans struggle to control costs. He provided important insight into pharmaceutical manufacturers’ strategies that aim to optimize appropriate patient access to the medications and products they need through various services that can provide reimbursement support.

Mr Albright began by describing the specialty drug landscape. Managing specialty drug costs is a strategic priority for payers. In 2012, specialty drugs accounted for more than a quarter of the total prescription drug spend, and over half of the $7 billion spent on drugs launched in 2012. Seven of the 10 top-selling drugs to be launched within the next 4 years are expected to be classified as specialty. By 2016, pharmacy drug spend is expected to reach $192 billion, and a sky-high total of $400 billion by 2020.

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Impact of HEOR on Payer Decision Making

There is increasing evidence that improving patient outcomes and cultivating value in the healthcare environment will require health economics and outcomes research (HEOR). Nicole Hengst, research director, Health Strategies Group, provided a unique perspective into some of the ways that payers can utilize HEOR to guide their decision-making practices.

Ms Hengst says her organization, Health Strategies Group, which provides market insight research to pharmaceutical and biotechnology professionals, conducted a survey of 71 payer executives from health plans, employers, and pharmacy benefit managers. It also included a more intense 30 minute interview process with 25 of those respondents. The survey probed into how these payers view HEOR studies, how they use HEOR studies to make access decisions in the top therapeutic categories, and how their decision-making or patient engagement processes are evolving due to the use of HEOR studies.

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Value Equation 2.0: Succeeding in the New Order of Value Driven Healthcare

While the fee-for-service (FFS) reimbursement model has long been accepted as the standard model in healthcare, it must shift to one that focuses on value. Value-based reimbursement will encourage stakeholders to achieve the triple aim: improve patient experience, better manage population health, and reduce per-capita costs of healthcare so that patients receive more for the dollar spent, said Dan Sontupe, executive vice president, payer marketing & market access, The Cement Bloc.

In the FFS diabetes management world, formulary design focuses on 1 or 2 preferred brands. There is standard contracting, co-pay cards (which are great for patients and annoying for payers), and a one-size-fits-all approach to treatment algorithms. Often patient education was ineffective due to understaffed offices that lacked case managers. Uncoordinated care among providers resulted in 1 in 10 healthcare dollars being spent on treating diabetes. What’s more, without change, 21% of us population projected to have type 2 diabetes.

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