Market Access

MMIT Reality Check on Non-Small Cell Lung Cancer Systemic Therapy (Aug 2020)

August 28, 2020

According to our recent payer coverage analysis for non-small cell lung cancer systemic therapy treatments, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

According to our recent payer coverage analysis for non-small cell lung cancer systemic therapy treatments, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

To help make sense of this new research, MMIT’s team of experts analyzes the data and summarizes the key findings for you. The following are brief highlights. To read the full piece, including payer coverage, drug competition and prescriber trends, click here.

Payer Coverage: A review of market access for non-small cell lung cancer systemic therapy treatments shows that under the pharmacy benefit, about 46% of the lives under commercial formularies are covered with utilization management restrictions.

Trends: When the FDA approved Novartis Pharmaceuticals Corp.’s Tabrecta (capmatinib) on May 6, 2020, it was the first of seven approvals in non-small cell lung cancer (NSCLC) through May 29.

Radar On Market Access: Large Employers Expect Cost Uncertainty, More Virtual Care in 2021

August 25, 2020

While the COVID-19 pandemic has not caused employers to significantly alter their health care cost estimates for the coming year, it has unquestionably intensified their interest in embracing virtual care. Those are just a couple of the major findings from the Business Group on Health’s 2021 Large Employers’ Health Care Strategy and Plan Design Survey, AIS Health reported.

Notably, 80% of respondents said they believe virtual health will play a significant role in how care is delivered in the future, up considerably from 64% last year. Further, when asked about actions they were taking to ease the burdens of COVID-19 for employees, the largest share of respondents — 76% — said they “made changes to allow for better access to virtual care solutions.”

While the COVID-19 pandemic has not caused employers to significantly alter their health care cost estimates for the coming year, it has unquestionably intensified their interest in embracing virtual care. Those are just a couple of the major findings from the Business Group on Health’s 2021 Large Employers’ Health Care Strategy and Plan Design Survey, AIS Health reported.

Notably, 80% of respondents said they believe virtual health will play a significant role in how care is delivered in the future, up considerably from 64% last year. Further, when asked about actions they were taking to ease the burdens of COVID-19 for employees, the largest share of respondents — 76% — said they “made changes to allow for better access to virtual care solutions.”

During an Aug. 18 press briefing, Business Group on Health President and CEO Ellen Kelsay attributed such findings to not only telehealth’s ability to offer more convenience and greater access for consumers, but also to the sheer necessity of pivoting to a different care modality amid widespread stay-at-home orders.

Regarding the controversial issue of telehealth reimbursement, which payers generally want to be lower than in-person visits but providers want to be equal, Kelsay said her organization supports payment flexibility over parity. In some cases, that “might mean less reimbursement for telehealth, and in other instances maybe increased reimbursement for telehealth if it’s a better modality for delivery, depending on the situation,” she added.

Kelsay also emphasized that there are still more questions than answers about how the pandemic will affect health care costs for companies and their workers. For 2021, the Business Group on Health is projecting the total cost of health benefits will rise by 5.3% — slightly higher than the 5% trend it predicted in the past few years.

“There is a lot of uncertainty around what is actually going to manifest itself in terms of costs, both this year and next year,” Kelsay said. “Many employers are having a really hard time from a budgeting and actuarial perspective working with their health plan and consulting partners, to really get a good handle of what that means.”

MMIT Reality Check on Ulcerative Colitis (Aug 2020)

August 21, 2020

According to our recent payer coverage analysis for ulcerative colitis treatments, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

According to our recent payer coverage analysis for ulcerative colitis treatments, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

To help make sense of this new research, MMIT’s team of experts analyzes the data and summarizes the key findings for you. The following are brief highlights. To read the full piece, including payer coverage, drug competition and prescriber trends, click here.

Payer Coverage: A review of market access for ulcerative colitis treatments shows that under the pharmacy benefit, about 69% of the lives under commercial formularies are covered with utilization management restrictions.

Trends: In July 2020, the FDA approved Mylan N.V. and Fujifilm Kyowa Kirin Biologics Co., Ltd.’s Hulio (adalimumab-fkjp) for the treatment of rheumatoid arthritis, juvenile idiopathic arthritis, psoriatic arthritis, ankylosing spondylitis, adult Crohn’s disease, ulcerative colitis and plaque psoriasis. The agency approved the biosimilar of AbbVie Inc.’s Humira (adalimumab) — the sixth one that the agency approved — in both prefilled syringe and auto-injector presentations.

Radar On Market Access: COVID-19 Pandemic Amps Up Interest in Home Care

August 20, 2020

As visits to hospitals and outpatient clinics have become sources of anxiety for patients worried about exposure to the novel coronavirus, plans and providers alike have begun to make major investments in home care, AIS Health reported.

Humana Inc., for example, recently announced a $100 million investment in home primary care startup Heal Inc. Heal CEO Nick Desai says his company will aid Humana’s long-term strategy to reduce the cost of care and improve quality.

As visits to hospitals and outpatient clinics have become sources of anxiety for patients worried about exposure to the novel coronavirus, plans and providers alike have begun to make major investments in home care, AIS Health reported.

Humana Inc., for example, recently announced a $100 million investment in home primary care startup Heal Inc. Heal CEO Nick Desai says his company will aid Humana’s long-term strategy to reduce the cost of care and improve quality.

Heal’s model places patients with a consistent primary care physician who makes house calls. The doctors are dispatched and routed using an app and driven to visits with a medical assistant, and they input notes and update care plans into an electronic health record between visits.

“Our doctors are paid on a salary basis, so they don’t worry about the billing,” Desai explains. “They have incentives and bonuses for delivering quality, but never for seeing more patients. We’re fundamentally economically aligned around the delivery of value, not volume.”

Where payers will find significant appeal in home care is in reducing the duration and number of inpatient visits, says Ashraf Shehata, KPMG national sector leader for health care and life sciences.

Shehata says that building home care capacity will give plans more flexibility to meet patients on their own terms and could improve outcomes in a post-acute context. Still, he suggests that there are substantial barriers to scaling up home care to that level. Those include regulatory standards, including special certifications that are required for licensed home care providers. He also notes lagging EHR interoperability impedes the flow of information between home care providers and other parts of the health care system.

COVID-19 has thrown a bright light on existing incentives for hospital systems to reduce inpatient stays. In the spring, Utah-based integrated health system Intermountain Healthcare launched a pilot program to move post-acute patients and low-acuity emergency patients to home care.

Nick Bassett, vice president for population health services at Intermountain subsidiary Castell, says the pilot is tied to health system’s longer-term value-based care strategy. He adds that the pilot has shown promising savings — mainly from reducing the physical plant and staffing costs of a hospital stay.

MMIT Reality Check on Duchenne Muscular Dystrophy (Aug 2020)

August 14, 2020

According to our recent payer coverage analysis for Duchenne muscular dystrophy treatments, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

According to our recent payer coverage analysis for Duchenne muscular dystrophy treatments, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

To help make sense of this new research, MMIT’s team of experts analyzes the data and summarizes the key findings for you. The following are brief highlights. To read the full piece, including payer coverage, drug competition and prescriber trends, click here.

Payer Coverage: A review of market access for Duchenne muscular dystrophy treatments shows that under the pharmacy benefit, about 49% of the lives under commercial formularies are covered with utilization management restrictions.

Trends: More recently, in August 2020, the agency gave accelerated approval to NS Pharma, Inc.’s Viltepso (viltolarsen) for people amenable to exon 53 skipping therapy.

Radar On Market Access: FDA Approved Two PARP Inhibitors for Prostate Cancer

August 11, 2020

Although poly ADP-ribose polymerase (PARP) inhibitors are not new to the market, two of them recently gained approval for use in prostate cancer for the first time. The therapies will bring a new option for the treatment of certain subpopulations of patients, AIS Health reported.

On May 19, the FDA expanded the label of AstraZeneca and Merck & Co., Inc.’s Lynparza (olaparib) to include the treatment of people with deleterious or suspected deleterious germline or somatic homologous recombination repair gene-mutated metastatic castration-resistant prostate cancer who have progressed following treatment with Xtandi (enzalutamide) or Zytiga/Yonsa (abiraterone acetate).

Although poly ADP-ribose polymerase (PARP) inhibitors are not new to the market, two of them recently gained approval for use in prostate cancer for the first time. The therapies will bring a new option for the treatment of certain subpopulations of patients, AIS Health reported.

On May 19, the FDA expanded the label of AstraZeneca and Merck & Co., Inc.’s Lynparza (olaparib) to include the treatment of people with deleterious or suspected deleterious germline or somatic homologous recombination repair gene-mutated metastatic castration-resistant prostate cancer who have progressed following treatment with Xtandi (enzalutamide) or Zytiga/Yonsa (abiraterone acetate).

On May 15, the FDA gave accelerated approval to Clovis Oncology, Inc.’s Rubraca (rucaparib) for the treatment of adults with a deleterious BRCA mutation (germline and/or somatic)-associated metastatic castration-resistant prostate cancer who have been treated with androgen receptor-directed therapy and a taxane-based chemotherapy.

Two other PARP inhibitors — GSK’s Tesaro, Inc.’s Zejula (niraparib) and Pfizer Inc.’s Talzenna (talazoparib) — are on the market, and both are in clinical trials for prostate cancer.

Lynparza’s and Rubraca’s approvals are “indicative of the growing knowledge we are gaining with respect to the intermediary pathways within the cells regulating DNA repair as it relates to tumor growth,” says Winston Wong, Pharm.D., president of W-Squared Group.

The PARP inhibitors will impact “refractory patients who have failed standard-of-care therapies,” notes Mesfin Tegenu, R.Ph., president of PerformRx, LLC. First-line treatment will be with antiandrogens or taxanes, he explains: Zytiga, Yonsa, Jevtana (cabazitaxel), Taxotere (docetaxel) or Xtandi. Then the top competitors in the second-line setting will be Lynparza, Rubraca and Keytruda (pembrolizumab), he says.

Asked how the two PARP inhibitors compare with other therapies in the class, Tegenu points out that “Lynparza had higher objective response rates and better radiographic progression-free survival compared to enzalutamide and abiraterone. It also showed benefit compared to docetaxel. Men with specific mutations may benefit more with PARP inhibitors.”

“Rubraca after receiving taxane therapy showed benefit,” he continues. “It is currently being compared to abiraterone, enzalutamide or docetaxel in an ongoing clinical trial. It has accelerated approval contingent upon verification of success in this trial.”