Pharm Exec Roundtable on Market Access - Pharmaceutical Executive

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Pharm Exec Roundtable on Market Access


Pharmaceutical Executive


Progress and pitfalls

Looney: Does the study identify the therapeutic areas most likely to set the agenda on market access over the next three years?

Barnett: Yes. We asked managed care decision-makers to identify the disease areas they would prioritize in managing drug utilization and expenditures during this period. Oncology came out on top, followed by rheumatology, diabetes, respiratory, orphan diseases, neurology, and obesity. The common link here is the impact that actions by both manufacturers and payers can have on addressing unmet medical need. Targeted therapies for cancer that address the etiology of the tumor is a clear example, and their novelty in raising the likelihood that the medicine will end up in the patients most suited for it suggests access can be secured at a premium price—a win for manufacturers. In diabetes, the number of new patients with all the co-morbidities of this disease continues to expand the market. Economically, it's a huge burden for payers and there is strong interest in any medication that will help lower the overall cost of treatment. We found too that the science of diabetes looks promising, with new classes of drugs coming on stream that attack the disorder in different ways. There is a big potential innovation premium here for industry.




Obesity scored the greatest increase in interest as a priority therapy over the forecast period. Some of the same co-morbidity factors driving diabetes are at work here. The pipeline for new products with fewer side effects looks promising. And payers appear willing to reimburse obesity treatments because of the impact on population wellness, which translates to lower health costs.

Looney: The biopharma business is uniquely affected by public policy and legislation. Can we identify from the study the key challenges coming on the regulatory front?

Barnett: Executives on the managed care side are very focused on the implementation of the Affordable Care Act. Uncertainty is the prevailing sentiment. It remains to be seen if this complex law is a growth opportunity. Will expansion of the Medicaid-eligible population as well as the individual insurance exchanges create a windfall of new customers whose healthcare needs can be met at reasonable cost, through a balance of young and healthy against an older demographic with serious health risks? Another issue is coverage rules for drugs, including formulary management and related design questions, which are impacted in turn by rules on whether manufacturers can offer co-pay offset and coupon incentives directly to patients in the exchanges.

The study also looked at the prospects for biosimilars. A bare majority of respondents from the managed care/payer side believe biosimilars will become widely available to US patients in the next three years; there is a stronger consensus that, if this happens, we will see downward pricing pressure on drugs that lead to meaningful savings for payers. Realistically, however, most payers contend that discounts of at least 30 percent against the originator brand will be required to deliver any real savings.

Finally, the managed care group struck a distinctive note on comparative effectiveness rules. Surprisingly, most aren't currently employing this evidence tool to shape decisions on formulary coverage. Interviewees said they are waiting for relevant government agencies like CMS to take action; many point to internal resource constraints as the culprit in their failure to making it a priority.

Structural transitions ahead

Jim Smeeding, National Association of Specialty Pharmacy: Did the study confirm the trend toward a blurring of the roles played by payers and providers in the healthcare system?

Barnett: Yes. The ACO model with its focus on episode of care as an alternative to traditional fee-for-service is viewed as here to stay. If payers want to reduce costs, it requires that they embrace the concept of active medical management; it's no longer financially viable to act as a passive third-party.


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