Thought Leadership

Our leading subject matter experts share their insightful analysis and points of view to help you stay abreast of industry trends

MMIT Thought Leadership

PBM GPOs: An Uncertain Shift

While vertical integration and consolidation within the U.S. health system has been a steady trend over the years, now we’re seeing it go even further with the creation of pharmacy benefit manager group purchasing organizations (PBM GPOs), which create yet another tollgate requiring payment in the drug therapy supply chain.

Approximately 80% of all prescription drug claims are managed by the top three PBMs: Express Scripts’ Ascent Health, OptumRx’s Emisar Pharmacy Solutions and CVS Caremark’s Zinc Health Services. Express Scripts, owned by Cigna, has set up Ascent in Switzerland. Ascent’s clients, in addition to Express Scripts and Cigna, include Kroger, Prime Therapeutics and Humana Commercial. Optum Rx, owned by UnitedHealthcare, has chosen Ireland as the headquarters for its GPO, Emisar. Zinc, the GPO created by CVS Health (which owns Aetna), is located within the U.S.


From Buy-and-Bill to White Bagging: The Future of Reimbursement Under the Medical Benefit

Pharmaceutical manufacturers that are nearing the commercialization stage of pre-approval planning are faced with a lot of realities about managed markets. Manufacturers are so engrossed in the details of a clinical trial, and its eventual success, that beginning to plan for commercialization can be daunting. However, for physician-administered therapies or IV therapies, understanding and navigating the nuances at play in the medical benefit landscape of payer organizations can significantly impact a product’s success.

Historically, access for medical benefit therapies was largely through buy-and-bill. Providers (integrated delivery networks [IDNs], clinics and practices) would acquire the product from the manufacturer via the manufacturer’s contracted specialty pharmacy wholesaler. The provider would hold that therapy at a financial risk but make up for it on the back end. Providers would seek reimbursement for administration and the cost of the therapy from the payer, and then they could mark up the cost of the therapy. This meant that reimbursement for a physician was largely impacted by how they negotiated the reimbursement rates with payer organizations.


Payers Are Using NDC Mandates, but Are They Doing Enough?

The drug development pipeline is dominated by specialty therapies, more and more of which are being managed under the medical benefit. Therefore, payers will increasingly need to manage those drugs themselves, given that the PBMs they’d normally rely on don’t process these sorts of claims.

As a result, payers are looking to better manage medical drugs, and one way of doing that is by implementing an NDC mandate—a trend that has been on the rise over the last five years. According to RJ Health’s recent NDC Mandate Survey, payers requiring the NDC mandate went from 62% in 2016 to 68% in 2021.


PrEP Therapy Can End the HIV Epidemic, but Equitable Access Is Key

Amid a global pandemic that has been the foreground of thought and development in medicine the past two years, another epidemic has been lingering for decades: HIV and AIDS were first recorded in the early 1980s, and their presence has grown exponentially over the last 40 years. In that time, HIV has fostered significant innovations and advancements across various fields including pharmaceuticals, access to care, public health education, and legislation, yet the U.S. still can’t seem to get control on the HIV epidemic.

Factors such as continued education around disease transmission and safe sex have been vital to reducing infection over the years, but in 2019, the government took steps to increase access to the daily HIV pill known as pre-exposure prophylaxis, or PrEP.


Case Study: Helping MarketLauncher Capture Success

For B-to-B companies, turning to a vendor can be a valuable lifeline when it comes to meeting client needs—so long as that vendor doesn’t delay the project or lead to missed deadlines.

When business development firm MarketLauncher was tasked with generating leads in the payer space for a new medtech client, the company needed a vendor that could not only provide the right data, but do so at speed.


Will New Approaches to Medical Benefit Contracting Help Control Specialty Drug Spend?

Pharmacy benefit contracting has always been a mechanism for payers to offset the cost of small-molecule therapeutic areas. Payers have looked to manufacturers to negotiate contracts that would prevent their products from being placed on a restrictive tier, or subject them to step edits or an NDC block.

But with the emergence of biologics driving the cost of specialty drugs managed under the medical benefit, more payers are looking for ways to implement tighter controls. This has now forced manufacturers to evaluate their current coverage and reimbursement strategy to determine whether medical benefit contracting could enhance their products’ positioning or protect existing coverage.


How Commercial Leaders Can Boost Sales Force Effectiveness

Two years of adapting to the constraints of a global pandemic has resulted in major changes to pharma companies’ commercial strategies. Now, as pandemic-related changes have started to become permanent fixtures, sales leaders are asking themselves key questions amid the shifting commercial landscape: How does my strategy need to evolve? How will it affect my field team’s workload and processes? What do HCPs expect from this new normal?


The Evolution of Patient Assistance Programs

It’s no secret that copay maximizer and accumulator programs have come under fire since their inception, and for good reason: In theory, these programs aim to help manage costs, but oftentimes accumulators can end up shifting the cost of medications to patients while maximizers can shift the cost of care from the patient to the manufacturer.

Now, amid the relentless tug of war between payers and pharmaceutical manufacturers, a relatively new type of patient assistance program has emerged. These programs—such as Paydhealth and MedMonk—work like savings aggregators, finding the maximum amount of savings possible to help patients pay less for their medications. Also, like copay accumulators and maximizers, they’re often a built-in feature within an employee benefits plan.


Betting Big on Biosimilars: How Evolving Market Dynamics Will Impact Patient Access

While the U.S. has been frustratingly slow to embrace biosimilars, the next few years are poised to see a veritable boom in new market entrants. Only six biosimilars were available at the end of 2018. There are now around 40 biosimilars approved in the U.S. across multiple indications. Plus, enrollment in the FDA’s Biosimilar Development Program has increased nearly 60% since October 2015, with more than 90 proposed biosimilar products in the program.


As We Head Into 2022, Here’s What’s Ahead for Market Access

While COVID-19 has left no industry untouched, it’s safe to say that healthcare has been hit the hardest. Yet despite this reality, there are plenty of exciting advancements happening within the industry, even amid the lingering effects of the global pandemic.

To get an idea of what’s to come in market access, I asked four of my colleagues to weigh in on upcoming challenges and opportunities within healthcare. Their answers—which cover topics from evolving payer strategies to gene therapies to digital therapeutics—are full of insights for the year ahead.