James and Dinesh offer four trends that they predict will shape medication access in the coming years. Click here to learn about consulting services from MMIT and its sister company The Dedham Group.
Read on for James’ and Dinesh’s insights.
Four Trends That Are Shaping the Future of Market Access
By James Pisano, Partner, Market Access, The Dedham Group and
Dinesh Kabaleeswaran, SVP, Insights & Advisory Teams, MMIT
Over the next few years, several more trends are poised to redefine how manufacturers, payers and providers interact. Manufacturers will need to stay abreast of the changing market access landscape—or risk falling behind.
Here are four trends to keep an eye on in the years ahead:
1. Evolving provider business models.
Business models for provider practices are changing. Consolidation and changes in ownership are becoming more common as the administrative and financial burdens of running a practice become more complex, with many formerly private practices being purchased by healthcare systems, payers, or private equity. Ownership structures can take many different shapes, each with their own impact on provider organization priorities, physician incentives, and access impacts.
There will be an increased influence of practice economics on prescribing. The downstream effects of practice consolidation and increasing leverage of provider organizations will have a direct impact on manufacturers and their local-level engagement strategy. With consolidation, we’ll see more pressure for medical benefit purchase discounts through the provider channel. Additionally, as care becomes standardized across multiple practices under the same ownership, treatment selection within the region may shift in alignment with financially incentivized organizational preferences. While it is unlikely that new ownership (i.e. payers, private equity, etc.) will mandate this alignment, it may become operationally simpler for physicians to do so.
Additionally, as health systems/IDNs and payers continue to acquire physician practices, the trend of vertical integration reaches new heights. This creates an environment more conducive to medical benefit management, enabling stronger pull through of payer policies/preferencing. We expect this to materialize in the form of “softer” management tactics, such as monitoring adherence to payer policies, rather than firm mandates to allow for physician autonomy.
There also will be an increasing influence of providers as access stakeholders. Provider business models are increasingly strained to keep up with rapidly evolving clinical standards of care, operational complexity in delivering novel treatments, coverage, procurement, and financial management challenges with tightening payer reimbursement.
As a result, providers are implementing their own operating models to maintain, or in some cases regain, control of the patient access experience and business model sustainability. This manifests in ways such as, but not limited to, pathways/protocols implementation, addition of new staff resources focused on revenue cycle management, and payer relationship evolution. This has driven increased need for market access teams to prioritize resource allocation to provider site access support.
Ultimately, this may increase pressure on pharmaceutical companies for rebates/discounts from both payer and provider channels. With increasing provider leverage and potential for strengthened medical benefit management, pharma will need to take a coordinated, local approach to their pricing and contracted strategy to minimize duplicative investments in access.
There will be an increased influence of practice economics on prescribing. The downstream effects of practice consolidation and increasing leverage of provider organizations will have a direct impact on manufacturers and their local-level engagement strategy. With consolidation, we’ll see more pressure for medical benefit purchase discounts through the provider channel. Additionally, as care becomes standardized across multiple practices under the same ownership, treatment selection within the region may shift in alignment with financially incentivized organizational preferences. While it is unlikely that new ownership (i.e. payers, private equity, etc.) will mandate this alignment, it may become operationally simpler for physicians to do so.
Additionally, as health systems/IDNs and payers continue to acquire physician practices, the trend of vertical integration reaches new heights. This creates an environment more conducive to medical benefit management, enabling stronger pull through of payer policies/preferencing. We expect this to materialize in the form of “softer” management tactics, such as monitoring adherence to payer policies, rather than firm mandates to allow for physician autonomy.
There also will be an increasing influence of providers as access stakeholders. Provider business models are increasingly strained to keep up with rapidly evolving clinical standards of care, operational complexity in delivering novel treatments, coverage, procurement, and financial management challenges with tightening payer reimbursement.
As a result, providers are implementing their own operating models to maintain, or in some cases regain, control of the patient access experience and business model sustainability. This manifests in ways such as, but not limited to, pathways/protocols implementation, addition of new staff resources focused on revenue cycle management, and payer relationship evolution. This has driven increased need for market access teams to prioritize resource allocation to provider site access support.
Ultimately, this may increase pressure on pharmaceutical companies for rebates/discounts from both payer and provider channels. With increasing provider leverage and potential for strengthened medical benefit management, pharma will need to take a coordinated, local approach to their pricing and contracted strategy to minimize duplicative investments in access.
2. Slow but steady transition toward value-based care.
We expect to see a continued trend of fee-for-service payment models evolving towards value-based care (VBC). To assess the impact of VBC on market access strategy, it is therefore important to understand how these trends differ by therapeutic area. Key factors such as the program stewards, sophistication of target provider organizations, and the maturity of VBC program design influence the access experience.
The stakeholders driving the VBC program may impact program participation, goals, and influence on treatment decisions. Consider two therapeutic areas: oncology and behavioral health.
Oncology VBC programs have been stewarded by a variety of national and regional stakeholders including CMS, payers, health systems, and third-party organizations. Due to the involvement of payers and the investment at a local health system/practice level, VBC adoption is widespread and well-integrated into the treatment paradigm. Alternatively, behavioral health has seen most programs stewarded by state Medicaid agencies or advocacy groups. This has led to significant variability at a regional level in the participation, sophistication, and impact of value-based care.
Across therapeutic areas, value-based care program structures range from optional participation to mandated reporting of quality metrics with reimbursement directly tied to performance. Innovative payment models associated with value-based care programs have largely been in a proof-of-concept stage over the last five years. Understanding VBC program incentives is increasingly critical to anticipate the extent to which VBC programs may impact access.
As VBC program participation grows for a provider organization, we see increased abilities to track and analyze quality metrics, new roles dedicated to care standardization and quality metric improvement, and development of resources to guide treatment decisions toward VBC goals. Provider organization sophistication in VBC program monitoring and performance improvement efforts can dictate how strongly VBC influences treatment selection.
Pharmaceutical companies will be increasingly pressured to align product value propositions and innovative contracting structures with national and local VBC program goals. Identifying provider organizations and payers demonstrating investment in VBC program participation and performance will highlight where engagement on relevant value proposition and contracting structures will resonate most.
The stakeholders driving the VBC program may impact program participation, goals, and influence on treatment decisions. Consider two therapeutic areas: oncology and behavioral health.
Oncology VBC programs have been stewarded by a variety of national and regional stakeholders including CMS, payers, health systems, and third-party organizations. Due to the involvement of payers and the investment at a local health system/practice level, VBC adoption is widespread and well-integrated into the treatment paradigm. Alternatively, behavioral health has seen most programs stewarded by state Medicaid agencies or advocacy groups. This has led to significant variability at a regional level in the participation, sophistication, and impact of value-based care.
Across therapeutic areas, value-based care program structures range from optional participation to mandated reporting of quality metrics with reimbursement directly tied to performance. Innovative payment models associated with value-based care programs have largely been in a proof-of-concept stage over the last five years. Understanding VBC program incentives is increasingly critical to anticipate the extent to which VBC programs may impact access.
As VBC program participation grows for a provider organization, we see increased abilities to track and analyze quality metrics, new roles dedicated to care standardization and quality metric improvement, and development of resources to guide treatment decisions toward VBC goals. Provider organization sophistication in VBC program monitoring and performance improvement efforts can dictate how strongly VBC influences treatment selection.
Pharmaceutical companies will be increasingly pressured to align product value propositions and innovative contracting structures with national and local VBC program goals. Identifying provider organizations and payers demonstrating investment in VBC program participation and performance will highlight where engagement on relevant value proposition and contracting structures will resonate most.
3. Investing in access.
Pharmaceutical companies’ understanding of access environments and potential barriers will help improve patient access to care. As payers and providers design systems to better enforce management and preferences, the industry needs to understand how their access strategies (e.g., payer rebates) correlate with streamlined access.
For example, if there is a weak correlation between payer policy positioning and utilization behavior, manufacturers may consider concentrating resources on supporting providers in the appeals/medical exceptions process as a more effective investment. Identifying the most efficient use of access resources and investments will be increasingly critical, particularly in concentrated, competitive environments. Strategic, focused investments in access will help to reduce pressures on gross-to-net that are not as effective in supporting clinically appropriate patient access to care.
Clinical trial data is increasingly referenced by payers in product coverage criteria and case approval decisions. As access channels tighten, manufacturers that present compelling product narratives to payers will achieve greater access. Currently, effective narratives typically look at a therapy through an HEOR lens, listing its clinical and economic benefits. Over the next five years, payers will care more about how those benefits tie to utilization and total cost of care. Providing a more integrated and cohesive narrative to payers will minimize clinically inappropriate access restrictions.
As data sets continue to expand to capture nuanced differences in coverage, utilization, affordability and reimbursement, pharmaceutical companies will have greater availability of resources to support informed access investment decisions. A holistic understanding of access barriers and opportunities to address them will help patients more easily access the medications they need in our increasingly complex healthcare system.
For example, if there is a weak correlation between payer policy positioning and utilization behavior, manufacturers may consider concentrating resources on supporting providers in the appeals/medical exceptions process as a more effective investment. Identifying the most efficient use of access resources and investments will be increasingly critical, particularly in concentrated, competitive environments. Strategic, focused investments in access will help to reduce pressures on gross-to-net that are not as effective in supporting clinically appropriate patient access to care.
Clinical trial data is increasingly referenced by payers in product coverage criteria and case approval decisions. As access channels tighten, manufacturers that present compelling product narratives to payers will achieve greater access. Currently, effective narratives typically look at a therapy through an HEOR lens, listing its clinical and economic benefits. Over the next five years, payers will care more about how those benefits tie to utilization and total cost of care. Providing a more integrated and cohesive narrative to payers will minimize clinically inappropriate access restrictions.
As data sets continue to expand to capture nuanced differences in coverage, utilization, affordability and reimbursement, pharmaceutical companies will have greater availability of resources to support informed access investment decisions. A holistic understanding of access barriers and opportunities to address them will help patients more easily access the medications they need in our increasingly complex healthcare system.
4. Renewed importance of omnichannel marketing.
Prior to COVID-19, payers and HCPs would try to meet in person or at conferences. But now, omnichannel marketing, with more targeted engagement over multiple channels, including social media, is becoming more common among manufacturers and payers. The trend is driven by the fact that patient journeys are more complex and HCP targeting needs to be more precise within a narrow time window.
Moreover, the number of specialty drugs continues to rise, competing with the space and time for payers and HCPs to absorb brand information. Predictive analytics and augmented reality can help pharma organizations develop more targeted and personalized product demonstrations and experiences. More than 60% of payers are more likely to recall a product profile's safety and clinical profiles when they've already been exposed to the brand through digital media, according to MMIT’s Message Monitor.
With omnichannel marketing, manufacturers can get more targeted engagement to entities that control market access, especially large institutions and IDNs. In 2024, an effective omnichannel marketing strategy is critical.
Changing business models and mergers, as well as shifting care models, are sure to impact manufacturers over the next year and beyond. Manufacturers will need to determine where to invest to increase product utilization, and how to incorporate omnichannel marketing into their business plans. Depending on your portfolio, value-based care also could play a role in your product positioning strategy.
Moreover, the number of specialty drugs continues to rise, competing with the space and time for payers and HCPs to absorb brand information. Predictive analytics and augmented reality can help pharma organizations develop more targeted and personalized product demonstrations and experiences. More than 60% of payers are more likely to recall a product profile's safety and clinical profiles when they've already been exposed to the brand through digital media, according to MMIT’s Message Monitor.
With omnichannel marketing, manufacturers can get more targeted engagement to entities that control market access, especially large institutions and IDNs. In 2024, an effective omnichannel marketing strategy is critical.
Changing business models and mergers, as well as shifting care models, are sure to impact manufacturers over the next year and beyond. Manufacturers will need to determine where to invest to increase product utilization, and how to incorporate omnichannel marketing into their business plans. Depending on your portfolio, value-based care also could play a role in your product positioning strategy.
While the marketplace will always be evolving, having a plan to tackle these challenges will help manufacturers save valuable resources and increase the likelihood that patients get access to the life-saving therapies they need.
Looking for expert guidance and advice to help you weather the changes ahead? Learn how MMIT and its sister company, The Dedham Group, can help.
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