Our leading subject matter experts share their insightful analysis and points of view to help you stay abreast of industry trends
In the complex healthcare analytics landscape, understanding the nuances of open and closed claims is critical for researchers and analysts. Open and closed claims each offer unique insights into the patient journey.
Open claims, sourced from various clearinghouses and warehouses across the U.S., present a vast collection of data, while closed claims, adjudicated by insurers, provide a detailed, individualized perspective. Open claims are rather like a wide-angle view of the forest, whereas closed claims are more like a view of the…
Our first post in this series discussed how early market access research, conducted in the 12-18 months before launch, helps pharma companies identify differentiators and establish accurate expectations.
As your organization moves closer to launch, your market access team will need to establish a commercially focused definition for your patient population. You’ll need to identify treating physicians, define the current standard of care, and establish how your brand will fit into the existing landscape. Critically, your team will also need to…
Before physicians prescribe a new therapy, they need to trust that it is the most effective and appropriate treatment for an individual patient. They need education on the drug’s efficacy and safety, dosing and administration, and the clinical criteria that define eligibility. They also need to know if the drug is affordable and accessible for their patients.
Although pharma sales reps typically convey all this information to HCPs during their in-person meetings, physicians have become much more selective about the companies…
According to our 2024 State of Patient Access survey, 81% of pharma companies are launching their market access planning much earlier than they did five years ago. By Phase I, one-third of pharma companies are already engaged in market access research, with most pharma companies (54%) engaged by Phase II – III.
What can manufacturers hope to learn about the competitive landscape so far in advance? From identifying a brand’s most valuable differentiators to establishing accurate expectations for launch, early market access…
For the past year, Medicaid has been the predominant topic of conversation for those who monitor insurance market share shifts. Medicaid enrollment peaked at 94.5 million in April 2023, when states resumed eligibility redeterminations after a multi-year pause. In the year that followed, Medicaid enrollment declined 10.4%, and has continued to plummet in recent quarters, with this channel losing nearly 4.9 million beneficiaries from Q3 to Q4 2023.
As a direct result of this decline, membership in health insurance exchange plans is…
Vertical integration between payers, PBMs, specialty pharmacies, and providers has grown in the last decade, with more negotiating power concentrated among a handful of major players. Now insurers are adding production arms into the mix, following CVS Health’s bid to cash in on the race for Humira biosimilar market share.
Adding a manufacturing arm brings undeniable advantages for PBMs, from better cost control to smoother supply chain dynamics. Payer-production entities can align an entire product distribution chain in their favor, excluding…
For manufacturers of medical benefit drugs, ensuring accurate provider reimbursement is essential. If providers are unaware of how to appropriately bill for a particular drug, their errors will result in claims denials, which in turn may lead them to stop prescribing that drug in favor of another. Inadvertent underbilling for services rendered is also a top provider concern, especially given the popularity of buy-and-bill procurement.
In an attempt to manage medical drug spend, a majority of payers are now enforcing an…
For years, many manufacturers have assumed that pre-market physician education was not strictly necessary unless their brand was the first to market or had a novel mechanism of action. With the advent of precision medicine, however, ongoing disease state education has become increasingly critical. Today’s molecular-targeted therapies have very different treatment paradigms, not to mention cost structures.
While it stands to reason that purportedly curative therapies, like those for hemophilia, would require more intensive education campaigns, the need for greater pharma…
Since its passage in 2022, many have speculated on the impact of the Inflation Reduction Act (IRA) on providers, manufacturers and payers—especially those with Medicare Advantage plans. Just over half of all Medicare beneficiaries are currently enrolled in a Medicare Advantage plan, and enrollment is projected to reach 60% of the eligible population by 2029.
The 2025 and 2026 plan years will see the full implementation of some of the largest Medicare changes, including the Medicare Drug Price Negotiation Program, which…
Although the biosimilar market is expected to continue growing over the next few years, adoption thus far has been somewhat slow and uneven. Recent research published in Health Affairs takes a look at how upcoming provisions of the Inflation Reduction Act (IRA) are likely to impact biosimilar coverage, concluding that both Medicare beneficiaries and the government could realize substantial savings if Part D formularies resembled those of employer-sponsored plans.
In Benefit Design and Biosimilar Coverage in Medicare Part D: Evidence and…
