Managed Markets: Why Access Is No Longer Just About “Tier”

SURE, FORMULARY TIERS ARE IMPORTANT.

But they are only part of the equation. By our definition, access is based on:

  • Reimbursement, including copays, coinsurance, and benefit coverage
  • Restrictions, such as prior authorizations and management edits
  • Management, including patient compliance, guidelines, pay-for-performance, and disease management

As a brand manager, you can use this broader definition of access to develop payer strategies and position your product against competitors. And while your brand team may view your product and category challenges as unique, many diverse categories share the same sets of issues. (See Figure 1, below.)

The Access Equation
The Access Equation

By grouping drug categories based on two key access levers—preferred reimbursement and restriction use—we have identified some common themes that you can use to better understand the access landscape—and what it means for your brand.

 

Segmentation Improves Access Strategy Effectiveness
Segmentation Improves Access Strategy Effectiveness

In Figure 2 (above), each scatterplot quadrant comprises drug categories sharing similar access challenges and presenting interesting differences. Most brands fall into one of four quadrants, based on their opportunity for preferred reimbursement and their restrictions:

  • Quadrant one: Categories with high barriers, poor reimbursement (upper right)
  • Quadrant two: Categories with poor reimbursement, few restrictions (lower right)
  • Quadrant three: Unmanaged categories (lower left)
  • Quadrant four: Restricted use categories (upper left) 

 

Categories with High Barriers, Poor Reimbursement

Brands in quadrant one (upper right) face heavy restrictions, such as prior authorizations and step edits, as well as few preferred reimbursement opportunities. Interestingly, this quadrant includes two very different subgroups of drugs. One subgroup includes categories with multiple low-cost, interchangeable options treating conditions with little unmet need, such as proton pump inhibitors. The other subgroup includes categories at the opposite end of the spectrum— high-cost, complex biologics with inappropriate use concerns, such as agents for multiple sclerosis.

If your brand falls in quadrant one, consider these tactics to improve your brand’s access:

  • Focus on preferred placement in prior authorization review criteria or preferred agent designation.
  • Emphasize clinical value messages if a drug is a complex biologic.
  • Consider contracting dynamics as plan price sensitivity rises, especially when few or no agents demonstrate superiority advantages.

Categories with Poor Reimbursement, Few Restrictions

Agents in quadrant two (lower right) rarely gain preferred reimbursement, although they do avoid restriction barriers. Examples include “marginal value” drugs with multiple, low-cost options treating conditions with little unmet need, such as drugs for benign prostatic hyperplasia. Other categories such as osteoporosis agents and anti-platelets face poor reimbursement because of product similarities and generic availability.

If your brand falls in quadrant two, it might benefit from these strategies:

  • Set realistic access goals for new agents, such as non-preferred reimbursement, unless they show a significant advantage over older agents. 
  • Emphasize contracting strategies, particularly in the wake of growing low-cost options. 
  • Understand specific payer rationale for restriction use and work to minimize the impact by educating field teams on pull-through techniques with physicians and patients.
  • Leverage restrictions by gaining advantages over competitors, such as better placement on a pathway or competitive use of preferred-agent step edits.

 

Unmanaged Categories

The brands in quadrant three (lower left) are in the sweet spot: They face few management restrictions combined with broad preferred reimbursement opportunities. These categories typically include multiple drug options with varied mechanisms that treat high-priority conditions, such as Alzheimer’s disease and asthma. Also included in this quadrant are “niche-value” drugs for conditions with high mortality and morbidity risks, such as antiretrovirals.

If you have a brand in quadrant three, consider these tactics to preserve your brand’s access:

  • Monitor market trends and competitive dynamics to protect access, not improve it.
  • Plan for the possible loss of preferred reimbursement as key brands lose patent protection. 

 

Restricted Use Categories

Drug categories in quadrant four (upper left) are subject to prior authorizations, step edits, and other management restrictions. However, most payers expand preferred reimbursement options to these agents to facilitate patient compliance. Examples include oral oncolytics and some antidepressants.

If your brand is in quadrant four, consider these strategies to improve brand access:

  • Realize that restricted use is a misnomer for the oncology segment—for now, most brands have largely unimpeded access.
  • Watch for increased oncology agent oversight over the next few years as payers take steps to control use.

As brand access grows more complex and competitive, brand teams should monitor how the two key access levers—preferred reimbursement and restriction use—are affecting their category. By doing so, they can develop tactics to protect their brands, now and in the future.

  • 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.

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