Pricing has never been more of a key issue for the industry than it is right now. Yet, even with the increased importance
of pricing strategies, a lack of focus on critical market factors leads many manufacturers to forego profits or increase their
vulnerability to aggressive payers. Aligning pricing and contracting can achieve a sustainable competitive advantage-if product
managers objectively assess a product's clinical benefits and address two key questions:
- Which segments of the market are sensitive to price, and how sensitive are they?
- What are the value and cost of improving formulary and reimbursement status at key customer accounts?
In each therapeutic and geographic market, the influence of pricing and contracting varies, requiring a different strategy
for optimizing share, revenue, and profit. Despite the uniqueness or complexity of any set of market conditions, economics
will dictate the optimal strategy. In certain circumstances, setting a high price and not contracting for managed care formulary
access makes sense. In other situations, it would be disastrous. This article demonstrates that assessing the market environment,
identifying the costs and benefits of alternative pricing strategies, and striking the right balance between pricing and contracting
are critical. (See "Rx Drivers.")
The Formulary Factor
Managed care formularies in the United States and national health system formularies in many other countries confound the
price-demand relationship by restricting access to some products in an effort to control costs. In the United States, formulary
structures with tiered patient co-payments, prior authorizations, and physician budgets are common. When third-party payers
shield patients from the real cost, then pricing is only one of several strategic options available to drive sales. Product
managers must apply a different economic framework when price effects are overshadowed by formularies that dominate prescribing
decisions. Specifically, they must compare
- the value of each formulary position for increasing share
- the cost of achieving or improving formulary position by offering rebates or other value-added services.
Contracting for preferred formulary status in key customer accounts-the "net price" decision-is a critical element of pricing
strategy. Often, it is the contracting tactics that differentiate the product in the market. Pharma companies can use managed
care contracting to target strategic customer niches, adapt pricing to reward share performance, align customer objectives
through creative win-win contracts, and avoid the deleterious effects of potential price spirals.
Physicians and Price
There is considerable debate about whether physicians know or care about the price of the drugs they prescribe. The authors'
research shows that doctors know about prices-especially the relative prices of key products-and that price sometimes influences
prescribing decisions. For instance, doctors are more price-sensitive when prescribing for mild to moderate conditions, and
they are sensitive to the price of prescriptions for chronic conditions.
Physicians are also more price conscious when prescribing for patients who must pay the full "out-of-pocket" cost. In some
situations, doctors purchase and administer therapies to patients, as with oncology products in the United States or with
many traditional prescription medications in Japan. They are usually reimbursed at a fixed amount for the product and its
administrative costs; therefore, doctors are often concerned with the spread between the price and the reimbursement rate.
In contrast, physicians are less concerned about price if the patient has an acute condition requiring treatment for a short
course of therapy. Even for chronic conditions, if the physician has tried several medications and encountered problems with
tolerability or lack of efficacy, he is far more likely to disregard price when faced with a decision for the next course
of therapy. Determining how much of the potential market for a product is price-sensitive requires product managers to understand
patients in the therapeutic area and the responsiveness of prescribers to price at each decision point: first-line choice,
second-line product switch because of lack of efficacy or side-effects, add-on therapy, and so on.
There are also significant differences in prescribing amoung various kinds of doctors. General practitioners are more likely
to begin new patients on less potent prescription medications than are specialists, who generally start patients at higher
doses. Similarly, systematic differences exist between the patterns of "heavy prescribers," who treat a large number of patients,
and physicians who treat only a limited number of patients of a specific type. Also, as a result of DTC advertising, patients
often have a certain brand in mind, or even a discount coupon, when they see their physician. New research from FDA says that
69 percent of the patients who ask for a specific brand ultimately get what they want.
For price-sensitive patient segments, market research about product demand provides product managers with the basis for optimal
pricing strategy. First, they can use market research to determine the demand for therapy at different prices for each physician
type and patient segment. That allows them to estimate the market share response to incremental changes in price and competitors'
possible price responses. From demand simulations, product managers can determine the price that provides the highest revenues
and profits. That type of analysis, when completed for each physician type and patient segment, provides an aggregate demand
profile that combines all segment information to identify the exact price that will maximize profits in price-sensitive segments.
(See "Demand Curves" and "Reaction Curves.")
Reimbursement, which can insulate patients and physicians from the full price of a therapy, is perhaps the most important
factor affecting demand for prescription pharmaceuticals. In the United States, roughly 75 percent of the population has prescription
benefits covered by third-party payers. And managed care organizations (MCOs) commonly institute a formulary of preferred
products to control pharmacy spending. Formularies can block products from reimbursement, specify patient co-payment differentials
for brand-name therapies, and require prior authorization for nonpreferred drugs.
Consequently, when prescribing for patients with "high control" formularies, physicians generally pay much more attention
to formulary guidelines than to the price of a therapy. When physicians share the responsibility for controlling pharmaceutical
costs on a per-patient basis, the influence of formularies is offset and price becomes more important.
Two trends demonstrate the increasing importance of successful contracting strategies for formulary position. First, MCOs
are moving toward higher co-payment differentials and more tiers. Second, some plans are exploring percentage-based co-insurance
payments in lieu of co-payments. One MCO's recent formulary reform provides a good example of both trends. The MCO introduced
a four-tier formulary in 2001 to differentiate cost-sharing provisions among all therapies, including injectibles, generic
therapies, and biotechnology treatments. For the first three tiers, patients face co-payments ranging from $5 to $45; for
therapies in the fourth and most expensive tier, patients are responsible for 25 percent of the product cost. Such cost-sharing
provisions indirectly influence physician prescribing by causing some patients to request less expensive medicines.
Getting the most from managed care
Formulary status and the elements of an MCO benefit plan-patient co-payments, prior authorization requirements, and so forth-have
more impact on physician prescribing for MCO patients than price does. Therefore, it is imperative for product managers to
identify the MCOs that are most able to affect prescribing through their formularies-those who can "move share"-to understand
what drives formulary decisions and to compare the costs and benefits of getting on formulary or improving formulary position.
Segmenting accounts by their potential to affect share through benefits structure and formulary control can help apportion
contracting resources. (See "Getting the Most From Managed Care.")