Upload
letuong
View
213
Download
0
Embed Size (px)
Citation preview
©2015 Roger Green + Associates, Inc.
Developing Robust Payer-Manufacturer Relationships
Explore the Managed Care Perspective
March 23, 2015
©2015 Roger Green + Associates, Inc.
Four thoughts you should take from the next 45 minutes
1. Contracting is about adequate commercial performance and good pricing; partnership is about shared vision
2. Plans are beginning to “touch the third rail” of oncology, although management in this category lags other high-priced disease classes
3. In the eyes of the Payer community, no BioPharma today has distinguished itself consistently as a willing partner
4. In the short-run, capitated oncology practices will emerge as negotiators for lower drug prices and product preferences
2
This area is evolving rapidly
©2015 Roger Green + Associates, Inc.
Get to know your presenters
3
Our journey to the podium today
©2015 Roger Green + Associates, Inc.
Strong relationships require success on three dimensions
4
Account Management
Economic Value
Products and Clinical Data
Payers are…
...People
…Purchasers
...Professionals
Manufacturers can engage payers as People, Purchasers, and/or Healthcare Professionals
©2015 Roger Green + Associates, Inc.
We asked payers to tell us how seven manufacturers perform on each relationship dimension
5
...People
…Purchasers
...Professionals
• Pursues pricing and placement commensurate with product value
• Pursues innovative contracting strategies• Produces useful HEOR tools and reliable HEOR data• Contract terms offer greatest net cost savings to plan• Manufacturer looks for opportunities to align with you
around shared goals
• Account manager listens to your organizational needs
• Account manager demonstrates professionalism
• Account manager takes ownership for developing the relationship
• Account manager has pleasant personality
• Account representative understands your business
• Produces and develops products that meet unmet needs
• Designs and executes clinical trials with meaningful endpoints and comparators
• Displays commitment to the well-being of patients
• Account staff is medically knowledgeable
Many components were tested within each dynamic
Answers reflected an extremely high levels of co-linearity, but there were clear differences in what drives
contracting vs. partnership
©2015 Roger Green + Associates, Inc.
Contracting success correlates to one key variable from each dynamic
6
Current Contracting Relationship
...People
Account representative understands your business; speaks strategically about business opportunities with you ...Professionals
Designs and executes clinical trials with meaningful endpoints and comparators
…Purchasers
Contract terms offer greatest net cost savings to plan
Successful contracting relies on doing everything well enough
©2015 Roger Green + Associates, Inc.
Partnership correlates solely to elements of commercial strategy
7
…Purchasers
Future Partnership
• Pursues pricing and placement commensurate with product value• Pursues innovative contracting strategies• Produces useful HEOR tools and reliable HEOR data• Manufacturer looks for opportunities to align with you around shared goals
Better relationships require common vision
©2015 Roger Green + Associates, Inc.
Long-term, stable relationships involve two dimensions
8
Execution and vision each play pivotal roles
ExecutionNot good enough
Good enough
Superior
Vision
Non-aligned
Aligned
Strength of relationship
Du
rab
ilit
y o
f R
ela
tio
nsh
ip
©2015 Roger Green + Associates, Inc.
Plans are converging on a common strategy to manage specialty drugs
31%
12% 11%17%
49%*
30%*
19%11%
6%*
0%
25%
50%
75%
100%
Pharmacy BenefitTechniques
Wean Physicians offDrug Revenues
Differential ASPReimbursement
Treatment PathwaysBonuses
Drug Capitation inOncology
% o
f p
aye
rs
Plans With Active Programs, 2013 vs. 2015
2013 (n=52) 2015 (n=47)
9
Pharmacy benefit-style programs continue to be the most-used options
Q2. We want to understand what strategies your plan is using (and intends to use in the future) to control the costs of specialty pharmaceuticals and other high-cost medications. For each potential strategy, please select the category that best fits your plan.
* P < 0.05
“Oncologists know this is coming and our goal has been to soften the blow so that they are better engaged and aware that they’ll be taking on [financial] risk.”
“A capitation cost model is the final step, we need to have robust EMR systems in place to make data-informed decisions for this.”
©2015 Roger Green + Associates, Inc.
Pharmacy benefit techniques are seen as more effective in general
3
2
2
4
5
3
5
2
9
16
0 5 10 15 20 25
Drug Capitation in Oncology
Wean Physicians off Reliance on DrugRevenue
Performance Bonuses on TreatmentPathways
Differential ASP Reimbursement
Pharmacy Benefit Techniques
Success of Active Programs, 2015n=47
Extremely
Somewhat
10
Differential ASP reimbursement scores 100% effectiveness rate
n=13
n=23
n=8
n=11
n=14
91%
100%
71%
64%
75%
“The [lowest ranked options] are the toughest work, and probably take a little bit longer… The other options, while important, are basically stop-gap measures in the interim, while broad, fundamental reform is taking place.”
“When you work in a business with supermarket-size margins, you cannot afford to think about the long-term.”
% who find their programs successful
©2015 Roger Green + Associates, Inc. 11
“Competition brings manufacturers to the table… Three or more (similar agents) starts to open it up, with four the dam really
opens up and manufacturers will have to buy share.”
“We need to pick and choose our battles and there’s not enough to play here yet… “There’s no price difference, why would we pick this
fight?”
Today, PD-1 management is not brand specific
Without more information or competition, the “fight is not worth it” on brand preference
28%
51%
9% 11% 13%
0%
17%
53%
11% 11%15%
2%
0%
25%
50%
75%
Not yetreviewed
PA tolabel/indication
Specialist-only Step-throughexisting agents
No barriers Not covered
% o
f p
aye
rs
Coverage for PD-1 Inhibitorsn=47
Opdivo
Keytruda
87%
9%
2% 2%Prefer neither
Anticipate preferringone agent in future
Prefer Opdivo
Prefer Keytruda
©2015 Roger Green + Associates, Inc.
Beliefs change with additional PD-1s on the market
12
Payers split into two segments: maintaining equal coverage versus contracting
58%*27%
15%
Please assume there are now four PD-1 inhibitors available and marketed. They are all listed at similar prices. What is the likelihood that plans will:
Cover all four PD-1 inhibitors equally
Actively seek to contracts, with the best contract receiving preferred coverage for their agent
Cover each agent tightly to label, but implement restrictions to provide preferred coverage for the agent with the best contract
16%
35%
49%*
SEGMENT 1 SEGMENT 2
n=3 n=6
“Once you get 3, 4, 5 products, then we will treat
them as a class.”
“There was [one company] interested in contracting for
their product, which we considered but then declined due to not enough volume to
justify rocking the boat.”
©2015 Roger Green + Associates, Inc.
Approaches to biosimilars are varied, with most payers leaning towards equal coverage
13
Payers do not exhibit the same patterns as with PD-1s
42%
33%
25%
A biosimilar of rituximab has been FDA-approved for similar indications and will cost ~20% less. What is the likelihood that plans will:
Immediately cover the biosimilar and actively encourage its use
n=9
30%
32%
38%
Cover all four PD-1 inhibitors equally
Actively seek to contracts, with the best contract receiving preferred coverage for their agent
Cover each agent tightly to label, but implement restrictions to provide preferred coverage for the agent with the best contract
n=9
Cover the branded agent only while waiting for more information on the biosimilar
Four PD-1 inhibitors listed at similar prices:
Immediately cover the biosimilar without taking a position on which one to use
©2015 Roger Green + Associates, Inc.
Payers: No manufacturers exhibit sensitivity to our economic needs
14
“Sensitivity…[is] directly proportional to competition in the market”
“Sensitivity to economic needs is not exactly a hallmark in the industry.”
0%
100%
Which manufacturer(s) exhibit sensitivity to your economic needs?
n=9
Company A
Company B
Company C
Company D
None
“We have some contracting for some of the supportive care categories but very little for infused high cost agents. Sensitivity to our needs tends to be directly proportional to competition in the market and the fear from manufacturers that they will be disadvantaged.”
©2015 Roger Green + Associates, Inc.
Payers: Manufacturers will listen and act on our business needs
15
Five of nine could name at least one company; answers varied
“So far we contracted only with Companies B and D in this arena not only due to these companies listening to our business needs but also due to the market realities in that category.”
“To be fair, there have been contracting openings given by Companies B and C, following fairly lengthy discussions, but we could not come to an agreement on details.”
1
3
2
1
4
0
1
2
3
4
5
Company A Company B Company C Company D None
Tit
le
Which manufacturer(s) show willingness to listen to business needs and act on discussions?
n=9
©2015 Roger Green + Associates, Inc.
Payers: Potential for alignment vis-à-vis therapies, biomarkers, risk sharing, HEOR metrics
16
QALYs and genomics pave the way to manufacturers assuming risk
“I will give credit to [certain manufacturers] and some smaller biotechs who are pursuing innovative breakthrough therapies. To me, the pursuit of unique mechanisms of action in previously unsuccessfully treated cancers is a defensible business model.”
Which manufacturer(s) show the strongest commitment to developing genuinely good medicine?
Which manufacturer(s) show alignment with payers in a vision for oncology?
“The best way I could foresee [to gain alignment] would be a willingness to rebate the cost of a drug that does not work for a given patient. In the interim, finding biomarkers or genomic tests to match the right patient would be the best interim strategy.”
“[The ones who have] did so by using biomarkers and making improvements on existing products or by developing a few breakthrough products.”
“[Alignment would come from a] commitment to reference pricing as done in other countries. Tie pricing to outcome measures (QALY-type metrics).”
©2015 Roger Green + Associates, Inc.
Plans anticipate dramatic changes in oncology guidelines
17
Cost is projected to become a major factor over the next 3 years
28%
43%
26%
43%
45%
36%
34%
45%
30%
51%
36%
21%
43%
26%
28%
38%
45%
34%
51%
34%
0% 50% 100%
Mental Health [K]
Hypertension [J]
Nervous System Diseases [H]
Heart Disease [G]
Dyslipidemia [F]
Asthma/COPD [E]
Joint Disorders [D]
Diabetes [C]
Oncology [B]
Hepatitis C Virus (HCV) [A]
Guidelines That Include Costs – Today and FutureN=47
Q5. For each of the following disease states, please indicate the status of guidelines that incorporate therapy costs
Disease State Rank
Today 3 Yrs from Now
1 1
8 2
2 3
7 4
6 5
3 6
2 7
10 8
5 9
9 10
85%GHJK
81%JK
79%jk
79%jk
74%
73%
69%
69%
64%
64%
©2015 Roger Green + Associates, Inc.
Factors that influence plans’ guidelines reflect disease categories
18
National guidelines are of extra importance in oncology
3% 4% 4%
45% 41%54%
20%34%a
26%
32%cd20% 16%
0%
25%
50%
75%
100%
Oncology[A]
HCV[B]
Mental Health[D]
% Im
po
rta
nce
Stated Importance in Setting Guidelines: 2015n=47
National guidelines(e.g., NCCN for Oncology)
Therapy costs
Clinical (Efficacy/Safety)
Manufacturer relationship
Q9. Now we would like you to assess the relative importance of different factors in determining your plan’s approach to setting guidelines for different disease states. For each disease state, please allocate 100 points so that each column/disease state sums to 100
Capital letters indicate statistical significance at 95% CILowercase letters indicate significance and 90% CI
“NCCN is the easy, go-to but they don’t define sequence. We’re trying to create oncology medical homes and using real-world data to drive decision pathways.”
©2015 Roger Green + Associates, Inc.
Payers anticipate that cost-centered approaches will have significant effect on overall healthcare spending
19
Provider efforts to control costs directly will increase
Q4. Please estimate what kind of an impact each of the following efforts have or will have on overall health spending in the United States. In considering your response, please weight how likely each outcome is to occur as well as how much impact it might have when it does occur.
26%
45%
37%
55%
41%
68%
54%
62%
7%
6%
7%
9%
15%
13%
15%
28%
0% 20% 40% 60% 80% 100%
2014
2015
2014
2015
2014
2015
2014
2015
% of payers
Positive Very Positive
Specific Treatment Guidelines Written with Therapy Costs in Mind
Scorecards to evaluate drugs based on cost/value alongside traditional
efficacy/safety measures
Creation and Promotion of “Wasteful Procedures” Lists
QALY-based “high” or “low” value ratings in practice guidelines and
performance standards
Impact of Cost Control Approaches on US Health Spendingn=47
90%*
69%
81%*
56%
64%*
44%
51%*
33%
* statistically greater than 2014, 95% CI
©2015 Roger Green + Associates, Inc.
The “two-tiered” cost management of the future
HCV Cost Managers Oncology Cost Managers
20
Pharmacy and medical cost managers will address aligned incentives
©2015 Roger Green + Associates, Inc.
Four thoughts you should take from the next 45 minutes
1. Contracting is about adequate commercial performance and good pricing; partnership is about shared vision
2. Plans are beginning to “touch the third rail” of oncology, although management in this category lags other high-priced disease classes
3. In the eyes of the Payer community, no BioPharma today has distinguished itself consistently as a willing partner
4. In the short-run, capitated oncology practices will emerge as negotiators for lower drug prices and product preferences
21
This area is evolving rapidly
©2015 Roger Green + Associates, Inc.
Thank you.