The managed care model has seen huge growth in the US pharmaceutical industry, with an estimated 85 percent of all prescription drugs now reimbursed through a managed care plan. It follows that gaining access to a managed care formulary can spell the difference between product plenty – and outright penury. But a formulary win alone is no longer sufficient to guarantee strong commercial returns through the full extent of the product life cycle Something more is required.
That something is an effective, outward-facing "pull-through" program to increase patient acquisition and retention to therapy, at each stage of the life cycle. Pull through programs focus on targeted messaging, qualitative insights and quantitative data benchmarks, all designed to help sales leaders understand how to leverage the local market influences that drive perceptions of access among healthcare providers. The goal should be to disengage the negative influences on product uptake and acquire or "pull" more patients into the brand.
Pull through programs are a response to a customer environment that is astoundingly dense and increasingly interdependent. It's not only payers who now control the levers on patient access to medication; there is an array of emerging stakeholders and influencers that set that perception, including Integrated Delivery Networks, Hospital formularies, Key Opinion Leaders, physician and organizational technology platforms, local standards of care, and national and regional healthcare policies.
What Is Pull Through?
"Pull-through" can mean different things to different people. Some define pull through as a process aimed at increasing market share and generating sales for a specific product within a given time frame. Others define pull through as broadcasting a formulary listing to enhance the value of managed care contracts. Others define pull through as a bridge builder to physicians. No matter how organizations define pull through, its practical application centers on influencing physician adoption of a drug that leads to increased patient acquisition, especially against competing therapies. The desirable outcome is that:
» Managed care, marketing, and sales executives understand how payer controls and patient affordability influence prescribing and dispensing at all levels of the market geography – national, regional and local.
» Sales reps and marketing teams are able to initiate and deliver a simple yet powerful message about the positive patient experience, to the highest value prescribers in the market.
Pull Through: The Payer Perspective
As companies seek to maximize a brand's access, the insurer/payer's own business objectives may be compromised. If the insurer believes it, will he demand retribution, such as in the form of a reduction or withdrawal of formulary status?
Another question is whether retribution is even possible. For example, if the pharmaceutical provider markets the only product that can cure or prevent a fatal disease, the payers' ability to set controls on patient use of this product is often limited, regardless of price. In this regard, it may not be a source of animosity among payers, as their core business model is optimizing profits by calculating and incorporating the risk (cost) of health care delivery (including all pharma products) in their premiums. Therefore, if the insurer has incorporated the costs of the pharma/biotech products in the current year's premiums, the insurer will likely still record a profit. However, insurer dissatisfaction may still exist as their customers (i.e., employers, government and individuals) see increases in premiums and cost sharing and hold insurers responsible for it. In other words, there is a potential reputation hit.
The quandary for the insurer can be summarized by the concept of "appropriate utilization." For the insurer, appropriate utilization is the primary goal of his value and service proposition to the customer. If a pharma company can help the insurer achieve this, it creates the ultimate "win-win" situation with insurers. It means that, for a specified medical loss ratio, the insurer is maximizing value to patients, meeting or lowering the health care cost portion of their premiums as well as keeping premiums affordable to customers.
To properly align the stars for this to happen, there are several things that must occur. If the product has good access (ideally on formulary with no restrictions, and where use of competitive products is inhibited by some controls), this positions it as among the more "cost-effective" options for the insurer. In this ideal situation, there will be a maximizing of market share along with augmented rebates for payers and lower insurer health costs. Both parties will want to extend and grow the use of this product. However, real life is so complex that most of big pharma's marketers, medical affairs and sales departments have not been able to implement the level of "appropriate utilization" most desired by the insurer. A key disconnect is the distrust between insurers and pharma based on the notion that only a "win-loss" zero-sum game can take place between the two parties, in such a competitive set of circumstances.
It's all about Standing Out!
The healthcare environment is becoming more complex, with emerging influencers in the market all attempting to either control the way healthcare is practiced or drive perceptions about products or services. This makes it harder for the healthcare professional to understand who actually has control in deciding what medicines the patient population is eligible to receive for reimbursement through multiple insurance plans. In response, companies are adopting a more customer-centric approach, through 'Go-To-Market' business models to help address the variability of influences that healthcare stakeholders have on the prescription decision-making process.
Even though pharma firms recognize that their commercial models need to change in line with the proliferation of outside influences on market choices, analytic tools and insights are only starting to emerge that will enable organizations to keep pace. These early deployments reveal some misalignments in terms of intentions and the actual outcomes obtained, such as:
» Differences between the true level of influence of stakeholders and the resources companies allocate to them.
» A majority of spend and resources is still focused on providers, with far less invested to understand the real underlying influences on healthcare providers and what factors determine their ability to treat the eligible patient population for various disease states.
The obvious conclusion? Pull through excellence makes it easier to understand the extent and nature of payer, patient, providers, integrated delivery networks, and all other policy influences at every levels of the decision chain, improving the prospect for brand success.
By identifying patient benefit designs structures, payer utilization techniques, patient affordability thresholds, physician perceptions of access, and organizational standards of care for each local market, organizations can start to craft the most relevant messages for use in driving physician adoption and productivity to capture new patients. Pull Through Excellence begins with:
» Best in class analytics to understand local markets and local perception of access.
» Processes that design optimal messages that can be delivered via push/pull sales and marketing strategies and tactics to maximize brand performance, especially in areas subject to competitive pressures. This can include focused opportunities with 'High-Value' prescriber target lists.
» Harmonizing resource investment based on trends that drive performance in local markets.
Key Questions To Shape Your Pull Through Strategy
Our research has identified the following as most important:
» How is overall brand performance influenced by the decision triad of the payer, patient and practitioner?
» To what extent is the prescribers' product selection determined at the pharmacy level?
» How does payer benefit design influence patient behavior?
- What benefit design controls do payers leverage to manage brand utilization?
» What are the key brand/switching patterns relative to the brand's competition?
- Is my brand losing or gaining patients? To which competitors?
- How does the payer influence brand initiation, conversion and adherence?
» Is the cost of the medication and patients' socioeconomic status impacting the patient's ability to start and stay on the medication?
- Are patients abandoning prescriptions?
- How does abandonment vary by territory, payer, prescriber and patient demographics?
» What is the influence of generic utilization on my brand?
- Are certain payers, patients or practitioners more likely to start or switch to generics?
» How can tactical selection, resource allocation and fine tuning of messages be enhanced by understanding the impact of influencers?
Here are a few common problems that lend themselves to resolution via a strong Pull through strategy:
Problem 1: Government and commercial payers continue to exert their influence on brand performance.
Implication: Declining brand performance for those brands not positioned well within a plan.
Implication: Continued loss of resources to promote brands and maximize their performance.
Implication: Brand margins will continue to decline and brand access will continue to become more expensive.
Problem 2: Brand switching to generics continues to increase as co-pay differentials impact patient decisions on brand and generic selection.
Implication: Continued erosion of brand utilization leads to declining brand performance.
Problem 3: Patients are less compliant and persistent than they have been in the past for many brands.
Implication: This represents lost sales opportunities for brands because of payer controls, patients unwillingness to pay, and the current effects of the economy.
Problem 4: Pharma has difficulty quantifying the degree that plan control impacts brand utilization at all levels of geography.
Implication: Not knowing this information hinders pharma's ability to set appropriate sales targets, and allocate appropriate resources.
Problem 5: Pharma continues to face budget cuts, staff reductions, and have less resources needed to cross-link siloed data sets
Implication: Missed opportunities created by targeting high-volume versus high value prescribers.
Problem 6: Pharma has difficulty determining the 'right' pull through message to deliver to the right prescriber.
Implication: Missed opportunity by delivering the wrong message to high-value prescribers leads to less optimal performance.
Problem 7: Linking together data from different siloed databases can be costly and lead to an incomplete view of the marketplace.
Implication: Pharma will continue to 'miss-out' on information critical to overcoming the challenges impacting brand performance at a national, regional, and local level.
Implication: Creates ineffective and siloed strategies and tactics among the different pharma stakeholders.
Assisting Account Managers
To assist the proliferating ranks of Managed Market Account Managers, which are now the most important cog in company sales channel strategies, we propose a five step approach to developing a Pull through excellence strategy:
Step 1: Pull through objectives should be centered around patient acquisition and prescriber initiation, adoption and productivity, with targeted capabilities designed to set the perception of access.
Step 2: Pull through excellence starts with a common definition and alignment across key stakeholders; one internal owner with executive level sponsorship and a permanent mandate to work toward ongoing success—to the end of the product cycle.
Step3: Pull through excellence requires a comprehensive understanding of capabilities, philosophy, processes, and people.
Step 4: Build a Pull through Excellence Engagement Model around a process to identify the areas that will benefit the greatest from increased attention, as follows:
» Identify most meaningful areas or brands that could benefit from pull through excellence approach.
» Scope out a proof of concept engagement model to propose to the business leads.
» Conduct Analysis and/or engage around proof of concept areas or targets.
» Roll out a Pull through Execution pilot program around a designated area established through proof of concept.
» Measure and evaluate the pilot's effectiveness. Discuss modification and or scaling.
Step 5: Conventional wisdom about managed markets can be misleading in this increasingly complex environment. The key question to ask is: Are we looking at managed care access through the wrong lens, given the preponderance of market changes?
A final pitch
Formulary position and payer-approved initiatives to influence physician prescribing are becoming more important in influencing and predicting prescription utilization. A successful pull-through program can benefit both the pharmaceutical manufacturer and health plan payer. By driving physician prescribing away from more costly and more restricted drugs, pharmaceutical company-initiated Pull through programs can increase market share while lowering the overall cost of the medication to the payer, employer and ultimately even the patient.
In conclusion, Pull through excellence strategies allow managed market teams to:
» Understand how payer controls, patient's willingness to pay, and prescriber receptivity impacts brand performance at all levels of geography
» Evaluate market conditions from the bottom up.
» Access information to favorably influence the primary drivers for their brands among physicians, payers and patients.
» Make better decisions on targeting, resource allocation, and promotion.
» Assess brand potential at a localized level.
» Measure performance and improve brand success.
Try it—it's a formula that will work, assuming the proper commitment.
Partha Anbil is Principal at the ConfluenceElite Group, LLC. Shiraz Hasan is Senior Principal, Managed Market Services at IMSHeath. Sanjay Bajpai is President of the Institute of Pharmaceutical Management. They can be reached at Partha.Anbil@ConfluenceElite.com
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