For years, payer strategies in the U.S. have had just one goal in mind: gaining access to the market for a medicine by securing coverage at a viable price. The approach has largely worked and seen market access cement itself as an integrated function within most companies. However, as value becomes the key consideration in health decisions, the narrow focus on coverage and reimbursement is no longer enough. If pharma is to prosper in the value-based era, emphasis must shift from the market to the patient—with U.S. payer strategies reorienting around the drivers of patient value to address broader barriers to care.
First, let’s be clear: the complexities of healthcare naturally dictate a holistic approach to access. Strategies must be mapped to the whole health ecosystem—payers, providers, patients et al. However, the center of gravity must always be the patient, with the objective being to ensure treatments reach all who need them in the shortest possible time. And in the U.S., plenty of obstacles are in the way. But a good payer marketing strategy can help overcome them.
To succeed, pharma needs to work to a broader definition of access that looks beyond availability and reimbursement, and instead focuses on ensuring appropriate patients can access products quickly, conveniently, and affordably. These are simple words, but they carry significant meaning for patients and providers:
- Quickly means giving physicians the ability to fill a prescription and initiate therapy without delay.
- Conveniently means ensuring the process of prescribing/procuring a product doesn’t burden or hassle HCPs, office staff, or providers.
- Affordably means ensuring patients’ out-of-pockets costs aren’t a barrier to initiating and adhering to therapy.
Failure to consider these factors when developing your payer strategy can have a big impact on patient outcomes. An example of this can be seen in a recent study of patients with severe asthma or urticarial, where insurance and specialty pharmacy delays in authorizing new biologic prescriptions left patients at risk of asthma attacks, emergency department visits, and hospitalization.
The study showed that patients who received a new prescription of monoclonal antibody therapy had to wait, on average, 46 days for treatment to be initiated. One patient waited 97 days. The impact of the delays was particularly severe among asthma patients:
- 51% had at least one asthma attack requiring a prednisone shot
- 40% of patients who had asthma attacks visited the ED
- 5% were hospitalized during the period they were awaiting their drugs
The study highlights how roadblocks in the provider environment can negatively impact outcomes—underlining the importance of payer strategies that address access barriers beyond coverage. How do you do it? Here are some essential steps.
Developing a holistic strategy isn’t just down to the payer team—it’s a collaborative exercise. It’s important to establish a multidisciplinary team (MDT) that captures perspectives from across the business, including brand, policy, advocacy, medical, and legal. These insights, along with input from external partners, are key to designing agile access strategies and customer-centered solutions. The MDT should be established early and engaged throughout the brand lifecycle.
2. Define All Elements of Access
Start by defining what access actually means for your specific therapy. This will vary depending on labelling and requirements. Once you’ve defined access, examine existing pathways to identify potential barriers. This will provide the baseline for your market access strategy.
The trick is to identify the critical success factors for access. These will guide solutions that ensure your therapy is readily accessible to patients, wherever they are. For example, for a physician-administered infusion drug in oncology, access means ensuring your therapy is available at both provider offices and hospital infusion suites—and that, no matter what, payers will support coverage and reimbursement in both settings.
3. Hit the Ground Running
Interim solutions that help physicians initiate therapies quickly are an important consideration. As the monoclonal therapy example shows, delays in filling prescriptions have real-world consequences. Interim solutions can help accelerate access when a therapy is first available. This is crucial. If providers and patients have difficulty accessing it early in the process, customer confidence can quickly erode and have a lasting customer experience. It’s difficult to bounce back.
4. Focus on Customer Experience
From a provider perspective, when it comes to prescribing and/or procuring a therapy, convenience is king. It’s important to understand customer needs from a business perspective taking into account geographic factors. For instance, some hospitals may not be able to proactively keep stock of costly specialty drugs. An effective payer strategy will identify this early and develop solutions to combat it. For example, consignment programs may help make drugs available to providers without the financial risk. Tailored payer marketing that educates providers on the options and reimbursement codes open to them is essential.
5. Think Beyond the Commercial Patient
Affordability and treatment compliance is everything. However, payer strategies must consider more on long-term outcomes. If the patient can’t be on a treatment long term, we won’t see the long-term clinical benefits. More often than not, the patients who could benefit most from a drug in the U.S. are Medicare, Medicaid, or even federal/government patients who can’t take advantage of copay cards. The value of a drug can only be realized if companies provide education and tools that encourage payers to make it available to all appropriate patients at the right time and place and for the complete duration of the treatment. The best tools will help them measure outcomes—whether that’s a clinical outcome or a healthcare quality score.
Ultimately, if a drug isn’t accessible, there is no value. Pharma companies therefore need to develop non-traditional solutions that overcome complex access barriers from the point of view of the ultimate customers (providers and patients) not just the payers. The best solutions won’t just focus on payer-centric issues, they’ll make the whole patient experience—and the provider roadblocks to it—their top priority.