While payers’ formulary decisions can make or break a drug’s success, manufacturers within oncology face an additional obstacle to gaining market access: clinical pathways, or guidelines that determine which treatments and procedures should be prescribed along the patient journey. While pathways were developed to help standardize treatment and ensure quality care, oftentimes they limit physicians’ prescribing decisions by restricting their choices to the products on the pathway.
Why is this important for oncology manufacturers?
Consider Martha, a 68-year-old who started experiencing severe stomach pain, recurring urinary tract infections and blood in her urine. Her primary care provider sends her to several specialists, and she undergoes many weeks of testing and lab work. After nearly two months of tests and worsening symptoms, she is assigned to a uro-oncologist and finally gets a diagnosis: Martha has late-stage urothelial (bladder) cancer.
Now, Martha’s oncologist must decide on the best course of action for her treatment. At the large integrated delivery network (IDN) where he works, the vast majority of oncologists base their treatment plans on a third-party clinical pathway. In this case, the pathway recommends that patients with late-stage urothelial cancer have surgery to remove the tumor followed by a prescription for the PD-L1 immunotherapy Keytruda. However, after identifying her treatment plan, there’s still one more step before she can receive the care that she needs: Martha’s health plan must agree to pay for it.
Fortunately, the health plan looked at Keytruda’s efficacy and cost and decided to cover it. While her patient journey up until this point was long and arduous, the surgery was successful, and she responded well to Keytruda. She is now in remission. Things worked out well for Martha—and for Merck, the manufacturer of Keytruda.
But what about the other PD-L1 immunotherapies on the market? Many are just as safe and effective as Keytruda and could make a meaningful difference in the lives of patients. In this case, because Keytruda was the only therapy on the pathway, the oncologist didn’t have visibility into other options; the IDN’s Electronic Medical Record system only shows the treatment options available on the pathway. As a result, manufacturers of other PD-L1 drugs are largely shut out of this market.
While Martha’s story is fictional, this scenario is all too real for both patients and manufacturers. To ensure that patients get timely access to the right treatment, oncology manufacturers need a holistic view of their barriers to access. In some cases, the payer’s restrictive coverage policy is the barrier, but in other cases it’s the lack of pathway placement that’s preventing physicians from prescribing a manufacturer’s drug in the first place. A robust data source—one that provides insights into both payers and pathways—is critical for learning how and where to focus your commercial efforts. For example:
- Is your product on an IDN’s pathway?
- Is your competitor’s product on an IDN’s pathway?
- Which IDNs use third-party pathways, and which use internally developed pathways?
- Are oncologists likely to make prescribing decisions that align with the pathway or do they deviate?
- Which influencers are advocating to get your drug—or your competitors’—placed on a pathway?
Without answers to these questions and an accurate understanding of the existing barriers, manufacturers could be spinning their wheels in the field or, what’s worse, making unnecessary rebate payments to payers.
Realizing the value of clinical pathways and ensuring coverage for patients like Martha starts with having the right tools. With critical patient outcomes at stake, manufacturers can’t afford to let inaction get in the way.
To see how MMIT can help you gain insight into payer and pathway-driven barriers to access, learn more about our Pulse Analytics solution.
This blog post is the first in a two-part series on ensuring access in oncology. Stay tuned for part two, where we’ll dive deeper into how oncology manufacturers can use payer and pathway data to improve their commercial strategies.