Managed Markets Access: 5 Oncology Payment Trends Revealed: How To Stay Ahead Of Uncertainty

For years, managed-care organizations have tried to reduce drug costs through generic substitution, denials, and other cost-management strategies.

However, one drug category that has remained relatively untouched until now is oncology. New research from Health Strategies Group suggests that more payers view oncology agents as a priority for management. What’s driving this change? High per member per month (PMPM) growth rates, concerns about inappropriate use, and a wave of new oral agents coming through the pipeline.

Fortunately, there are tactics that manufacturers can use to prepare for more rigorous payer management in the oncology market, and these core tactics can help propel brands forward. Health Strategies Group reveals some key oncology market changes based on the top trends in payer management.

Emerging Trend No. 1: Payers will expand member cost-sharing of oncology agents. Industry Response: Develop patient-centric marketing programs.

To prepare for increased member cost-sharing, companies should: 

  • Offer patient assistance and cost-sharing programs. 
  • Explore new contracting strategies that focus on gaining favor through restrictions rather than reimbursement.


Oncology Brands Lose Immunity

Oncology Brands Lose Immunity

Emerging Trend No. 2: Plans will control use through rigorous drug utilization management by implementing clinical pathways.

 Industry Response: Influence clinical protocols. To prepare for more rigorous drug utilization review, companies should: 

  • Watch for “first movers,” such as health plans with high volume and strong  relationships with physicians, to monitor their progress in implementing clinical pathways. 
  • Provide clinical evidence that demonstrates why their product should be in an advantaged position along the pathway.
  • Encourage physician advocates to influence payer-driven clinical pathways to optimize brand placement. 

Emerging Trend No. 3: Plans will restrict access through more pharmacy department oversight of office-administered agents.
Industry Response: Leverage organizational knowledge. To better serve the pharmacy department, pharmaceutical and biotech companies should:

  • Engage account management teams to assess customers’ progress in increasing pharmacy oversight. 
  • Prioritize activities with customers that present the greatest opportunities and threats.  
Trend #3. Expanding Pharmacy Department Role
Trend #3. Expanding Pharmacy Department Role


Emerging Trend No. 4: Brand review criteria will become more stringent.

Industry Response: Demonstrate value.

To address increasingly restrictive criteria, the industry should:

  • Ensure brands have data that shows proven efficacy gains. 
  • Demonstrate that it can deliver value to managed-care organizations through reduced medical costs, comparative effectiveness data, and other measures.  
Trend #4: Evolving Brand Review Criteria
Trend #4: Evolving Brand Review Criteria


Emerging Trend No. 5: Plans will add more access restrictions in managing biologics.

Industry Response: Rethink contracting platform.

To prepare for greater access restrictions, the industry should:

  • Negotiate access advantages for oncology brands with large market share before more steps are added in their reimbursement process.
  • Use contracting strategies to avoid step edits and gain preferred reimbursement positions.





  • Susan Weber

    Research Director with Health Strategies Group where she manages the Brand Access Analysis services. Susan has 20 years of diverse healthcare experience with expertise in studying the payer landscape to determine access issues across more than 30 drug categories.

  • Robert Shewbrooks

    Robert Shewbrooks is a Principal and Practice Leader with Health Strategies Group, where he leads the syndicated studies efforts for commercial MCOs. Bob has more than 30 years experience in marketing analysis on both the supplier and manufacturer sides of the pharmaceutical industry.


You May Also Like

Healthcare Highlights

FOLLOW THE BRANCHES This info graphic from CMI shows that in most cases an ...

Market Watch: Managed-care Coverage Still at the Heart of Cardiovascular Market

The market of products that treat cardiovascular conditions is massive, with hypertension and cholesterol ...