Our leading subject matter experts share their insightful analysis and points of view to help you stay abreast of industry trends
Payers tend to manage high-cost, high-complexity disease states quite differently than other indications. In recent years, payers’ growing reliance on managed care carveouts, in the form of specialty benefit managers (SBMs) and alternative funding programs (AFPs), has directly impacted pharma companies that offer patient assistance. This year, the downstream effects of the Inflation Reduction Act (IRA) and changes to Medicare Part D benefit will also play a role in patient access.
For pharma companies that offer a patient assistance program (PAP),…
As of 2024, more than 54 million Medicare beneficiaries had prescription drug coverage through Medicare Part D. Of that total, 31 million had Part D coverage alongside a Medicare Advantage plan, and about 23 million had a Part D prescription drug plan.
As a result of the Inflation Reduction Act (IRA), significant changes to the Part D benefit will take effect in 2025. Changes include a reduced out-of-pocket maximum, elimination of the coverage gap, continued drug price negotiations for selected therapies,…
The progressive integration of AI within medicine is transforming the way physicians evaluate and monitor disease, enabling earlier detection and improving outcomes and quality of care. Medical practices are increasingly leveraging datasets, algorithms, and other machine learning techniques to identify subtle patterns that might not be discernable to physicians without this technology.
These AI tools are especially useful in detecting conditions like early-stage cancer, cardiovascular diseases, and neurological disorders. For example, AI can analyze imaging data, such as CT and MRI…
Patients have expanding options for where to receive and take their medications. Both payers and manufacturers can capitalize on these options to improve patient access, adherence, and outcomes.
Within many therapeutic areas (TAs), medications that were previously covered by the medical benefit are now covered by the pharmacy benefit. To accommodate the new benefit designs, payer preferences regarding sites of care and routes of administration are also shifting. These changes have allowed payers to better control specialty drug spending.
Traditionally, patients…
The past few years saw the launch of several direct-to-consumer (DTC) programs, including Amazon One Medical and Mark Cuban’s Cost Plus Drugs. In 2024, several manufacturer-designed DTC programs, such as LillyDirect and PfizerForAll, have been added to the mix, demonstrating pharma’s continuing shift toward an integrated model of patient care.
While these programs can benefit multiple stakeholders, pharma companies should be aware of the existing and potential challenges before rolling out such a program.
Multiple Benefits for Stakeholders Patients stand to…
The weeks preceding a pharma product’s launch date are a critical window for market access teams. The ability to pivot and adjust to last-minute shifts can make all the difference between a successful first year and a disappointing launch trajectory. While much of your market access research may have already been completed by the time you go to market, there are several ways your team can continue impacting coverage and utilization.
Our first post in this series discussed the benefits of…
As the pharma industry continues to adjust to the provisions of the Inflation Reduction Act (IRA), the country will soon be ushering in a new presidential administration—leaving the future of the IRA in question. Despite ongoing regulatory uncertainty, manufacturers will still be focused on the same concerns: drug development, pipeline performance and ensuring patient access to their therapies.
To better understand what 2025 might bring, I asked three of my colleagues to share their perspectives on upcoming market shifts. Their answers…
Initially developed to manage type 2 diabetes, glucagon-like peptide-1 (GLP-1) agonist medications have become exceptionally popular for weight loss. High-profile celebrity endorsements and widespread media coverage has led to an overwhelming spike in demand.
By any estimation, the American market for weight-loss GLP-1s is enormous. According to a Kaiser Family Foundation analysis, more than 40% of privately insured adults under 65 are clinically eligible for a GLP-1 drug to treat obesity. Although there are several GLP-1 agonists on the market, only…
In recent years, pharma companies have begun to embrace lab data as a richly rewarding dataset for a whole host of purposes, including trial enrollment and site identification, patient monitoring and disease progression, and commercial targeting and market access insights. Along with test orders, values, and results, deidentified lab data includes a wealth of information, such as a patient’s demographic information, diagnosis codes, and ordering provider and facility details.
In addition to providing a deep understanding of a specific patient's clinical…
During the pandemic, the number of individuals in the U.S. enrolled in both fee-for-service and managed Medicaid programs increased dramatically. This increase was tied to a provision in the Families First Coronavirus Response Act, which boosted federal dollars to the states in exchange for keeping individuals covered through Medicaid, even if their eligibility changed since they enrolled.
In April 2023, states resumed eligibility redeterminations, leading to a steep and continuing decline in Medicaid enrollment. In the last few years, Medicaid unwinding…
