Brand Strategies and the Growing Influence of IDNs

The growth of provider networks such as integrated delivery networks (IDNs) has gotten significant attention in the healthcare space of late, one recognition becoming increasingly apparent: the barometer of influence is tipping, with physicians no longer the sole gatekeeper of clinical decision-making. But little notice, some experts argue, has been paid to equipping pharmaceutical companies with the ability and tools to manage this shift. Designing commercial strategies that consider the roles multiple stakeholders now play in treatment decisions is critical for drugmakers-as is deploying those strategies in line with a disease segment’s overall quality of care and outcomes, rather than just through the lens of a single brand approach.

“We should be driving toward that space where what’s the value of my product to the total impact of care?” says John Daly, senior principal, U.S. Pharma Solutions, IMS Health. “The fear around how do I create a strategy that will work everywhere is real-we don’t have that [yet]. We need to identify those key stakeholders in each region that are influencing these treatment decisions and identify their goals and their initiatives. Then a pharma organization has the ability to activate the right set of value propositions, brand strategy, and field tactics to align to those stakeholders that are critical in each of the regions.”   

Accomplishing this, however, is fraught with challenges, Daly acknowledges. For example, in an IDN, the needs of the members-whether a hospital, facility, or provider-along with the geographies they serve, can be very diverse. IDNs also often vary greatly in how they operate. And though pharmas recognize the value of new approaches to IDNs, there is still that lingering industry reluctance to change standing in the way, John Moran, senior principal, Managed Services, IMS Health, tells Pharm Exec.

   To that end, companies like IMS Health-through new metrics platforms and data and consulting services-are working with drug manufacturers to enable better identification of influencers and gatekeepers in the new hospital and provider environment (IMS published a whitepaper on the topic earlier this year http://bit.ly/1CsfO3Y). Daly and Moran recently spoke with Pharm Exec on new ways IDNs are impacting the healthcare decision landscape and the advantages of what they call “smart targeting” in this area. Here are some excerpts.

PE: Can you explain the concept of “smart targeting” as it relates to IDNs?

Daly: When you look at these IDNs, they are regional entities that are meant to link the community to care around things such as population management and quality and integrated care. Because of that, it is less viable to have a single US marketing strategy or field deployment. It’s important that we’re evolving to more of a local-driven stakeholder-based model. Without the ability to identify the stakeholders locally that are really influencing brand choice, treatment protocols, treatment pathways, or disease management, it is very difficult to have a locally driven model.

The first thing we think about in “smart targeting” is determining if in the region, IDNs are having an impact; if so, which IDNs, and beyond that, what are they doing with that influence-which classes or treatment protocols are they driving?

To date, the industry would look at factors such as this IDN is a teaching institution, it has electronic medical records (EMRs), it has some pay-for-performance contracts, or it has a no-rep policy. Because of these characteristics, [it was concluded that] they must be highly controlling or highly influential. We knew we could do much better than that. There’s a couple of major flaws there, the biggest being that it’s therapeutic agnostic. When we just look at attributes of control, they’re not specific to a therapeutic area or a disease state. When we look at the way we are targeting now, we’ve integrated very large previously separate but important data assets. We’ve pulled together affiliation data, payer data, and patient-level prescriber data. We’ve integrated it all in one stakeholder database, so that at the local level we can isolate if the IDN is having influence.

The way that we determine influence is that the affiliated physicians are prescribing with uniformity and variability compared to the community and the payer. To boil it down, we want to see, in the behavior of the prescribers, that they’re treating these disease states because they’re affiliated to the IDN in a specific way. Then we layer in the qualitative data. If they do have influence, how are they doing that? That’s what we determine as smart targeting.                                                                                                          

PE: Beyond such macro factors as payment reform and risk sharing, what are some other driving forces behind the evolution in care delivery models like IDNs?

Moran: One is how the health system has moved to more of a patient-centric approach to care. It’s not just about prescribing protocols around cost containment, but it’s really considering aspects of patient care that help to distinguish a health system. Then there’s also visibility in the care variation. As data gets more robust and gets joined up with EMRs, with clinical claims, specialty pharmacy information, etc., some of the larger IDNs have a much clearer picture of what’s happening in their care process-between specialists, primary care, hospital, community, etc. It’s becoming more visible in terms of care gaps and variation in prescribing.

The third factor is new types of value-new ways to engage the providers within the system and patients with services and support that are becoming available. For example, case management that’s being offered by certain support organizations, or the ability of patients to be more self-empowered and use applications that are customized. All of that is a mix of factors that come into play in the local geography that shape those specific care delivery models. For manufacturers to really engage, they have to have a good understanding of how those models are different locally and to change their engagement model to become more agile and more flexible to what’s taking place in the community.   

PE: Is there a greater need, then, for better performance metrics to help companies execute those strategies?

Moran: The kind of metrics that could be set are only limited by the strategic vision of the product manufacturer. Let’s say you want to measure the time from the refractory regimen to a more optimal therapy. How long does it take the health system to recognize and see that? What level of frustration does a patient and provider have to go through until an optimal therapy is prescribed and part of the regimen for the patient? That time difference is going to be varied across the United States. Bringing in information around that time gap is only going to benefit the patient. Different health systems and large provider groups can understand where they fit in therapy and can make adjustments to their care process. It says nothing about the product; it says everything about wanting patients to achieve the best possible of outcome.

We see that product manufacturers can capture an enormous amount of information about patients, what they go through, and their emotional journey. But we don’t see that put into play with the healthcare systems in terms of communicating and educating. Another words, it stays within the organization. We also understand the regulatory and compliance factors that go with it. But figuring out a way to be helpful and valuable in therapy is what will unlock access and will gain more dialogue and collaboration with the health systems.               

PE: How is the increasing influence of payers, specifically, driving the need for new ways to evaluate IDN impact on pharma brands?

Daly: The line between a payer and a provider network, in this case being the IDN, is really beginning to blur. In the Affordable Care Act, there was the launch of these  accountable care organizations (ACOs). An ACO is the integration of the payer and the provider network. In the US now, there’s many more commercial ACOs. When you hear the leadership of the national payers, they recognize that processing claims is not their value proposition for the future. That’s why they’ve chosen these commercial ACOs as a path to become more like a provider network. They recognize in the triple-aim of reducing costs, improving patient experience, and achieving better outcome, they need to be in the middle of that model.

At the same time, we’ve seen IDNs become insurers. In 2014, a big example was North Shore-Long Island Jewish, the largest employer on Long Island. It realized that it could offer the entire suite of patient care to employers on Long Island. So they are now a payer. Ascension Health, the country’s largest IDN, announced that they’re going to become a payer http://bit.ly/1aLLANP. We’re seeing IDNs become payers and payers become IDNs in collaboration with provider networks. Some may say is it any different than HMOs of previous decades? We think absolutely, for two reasons. One is it’s health information technology-the ability to measure through EMR. The second is the payment model is becoming integrated into the care model and IDNs and payers aren’t collaborating. That is a lot of influence. But it merges the focus of a payer on brand versus generic or preferred versus non-preferred brand with the focus on a broader physician-care model where you’re looking at the total outcomes and population management.

PE: Are there existing technology limitations in surveying the interactions between IDN stakeholders?

Moran: Traditionally, it has been a very siloed and fragmented system of care between the stakeholders. The focus has always been on that last link in the chain-the actual writer of a prescription or the payer that’s actually paying for the prescription at the pharmacy. Our view is that you really do need to understand the influences that are occurring that are both economic and clinical. Technology can help, certainly through data integration of these different data sets that are out there. But it comes down to the common core, which is the patient. It’s about understanding all the influences and how care actually gets delivered to patients and how they’re responding. Applying technology such as multichannel marketing to non-traditional stakeholders in the IDN would be effective. Consumer-oriented technology that continues to empower the patient and drive demand for improved care is certainly a key aspect now, with the new marketing mix.   

PE: Will this movement to more integrated care require pharmas to essentially redesign their commercial models to ensure they have the right skills and tools in place?

Moran: Yes, it does require a different set of skills and competencies to engage with these stakeholders. It’s no longer more of a product-centric skillset that’s an effective commercial strategy. It’s now about bringing in an in-field health economics capability, an expanded role for medical science liaisons, even introducing patient case management support. Or even just helping an IDN with a technology specialist to integrate a particular tool, application, or patient survey right into their EMR system. There’s a lot of variation and a lot of ideas that could be implemented based on the needs of the market.

PE: From a purely growth standpoint, how do pharma companies stand to benefit from IDNs in the future?

Moran: It is a debatable topic within the industry as to the value, importance, and impact of IDNs. If you could put aside the initial threats-generic utilization, reduced physician access, restricted protocols-and your brands represent differentiated therapy and capability, there’s potential for disproportion growth and more separation between competitors. We feel there are opportunities, depending on how well manufacturers recognize and understand the needs of these organizations, and their ability to meet those needs. It still puts a stronger emphasis on value solutions, so the job is harder, but the potential payout can be more, too.