Spotlight on Market Access

The FDA recently approved a third agent to treat paroxysmal nocturnal hemoglobinuria (PNH). With some conditions, that number of treatments may prompt payer preferencing, but that is unlikely to happen with this ultra-rare, potentially fatal disease, observe industry experts.

Kaiser Permanente, founded in 1945 as a consolidation effort between local hospitals in California and an insurance group for construction employees, has since become the largest integrated delivery network in the U.S. The company operates 39 hospitals, employs more than 20,000 physicians in its medical groups and offers health insurance products in both the private and public sector markets. Kaiser’s seven regional managed care plans enroll more than 11 million lives in eight states plus the District of Columbia. The seven combined entities form the largest provider-sponsored insurer in the U.S., enrolling 29.5% of all provider-sponsored lives.

CVS Health, seeking to leverage its success in COVID-19 vaccine and therapeutics clinical trial recruitment, has opened the doors on a new clinical trial services division that it hopes will offer life sciences companies the opportunity to recruit more diverse study populations.

Forecasting in the pharmaceutical industry is an essential task for companies. While firms have long used Excel-based models to conduct forecasts, those models are outdated and unsuited for the sheer amount of data currently available, maintain industry experts who point out that multiple Web-based options exist. In order to give an accurate picture that’s useful for everyone from executives to sales teams, forecasters should create a model that offers detailed segmentation of the market. Doing this is easier said than done, but strategies exist to help evaluate the different options.

Humana Inc. and Anthem, Inc. are teaming up with hedge fund administrator SS&C Technologies Holdings, Inc. to create DomaniRx, a new joint venture that aims to offer a “best-in-class” PBM cloud-based claims adjudication platform. Humana will be the first customer for DomaniRx, the companies say, and industry observers predict a potential market among Blues plans and Medicare Advantage plans.

Seven states have moved this year to cap out-of-pocket expenses for diabetic patients’ insulin, a trend that should help a small group of people who generally are uninsured or have high-deductible plans and have struggled to afford their medication. But it is unlikely to expand beyond insulin or impact health plans’ bottom lines, industry observers say.

CMS’s annual release of Medicare Part D payment benchmarks and other bid-related information for the coming plan year tells pretty much the same story as in years past. The national average bid amount will continue to go down, while reinsurance amounts will continue to rise and premiums will see a slight increase.

Earlier this month, Colorado signed into law a measure that caps total out-of-pocket spending on insulin for all diabetic patients. Under the bill, patients will pay no more than $100 for a month’s insulin supply. List prices for insulin have risen rapidly in recent years, and the average out-of-pocket cost of a full-year supply of insulin reached $613 for a privately insured patient and $1,288 for an uninsured patient, according to a Commonwealth Fund study based on Medical Expenditure Panel Survey from 2014 to 2017. To address the cost burden for diabetics, at least 17 states have implemented some type of monthly copayment cap for insulin. In addition, 46 states and the District of Columbia have insurance mandates related to diabetes coverage.

Following May 2020’s seven FDA approvals in non-small cell lung cancer, May 2021 brought only a pair of new NSCLC agents. However, these two drugs are significant because they were the first to gain FDA approvals for their specific indications. According to Zitter Insights research, the drugs should have good uptake among payers.

High prescription drug prices continue to be of concern at the federal level. Signaling the administration’s strongest action so far on drug pricing, President Joe Biden on July 9 unveiled his Executive Order on Promoting Competition in the American Economy. And earlier this month, HHS issued a proposed rule seeking to rescind the Most Favored Nation (MFN) drug price model, saying it instead was exploring value-based care options for the Medicare Part B program. However, it remains to be seen whether any significant changes are going to occur any time soon, say industry experts.