Many oncology manufacturers assume that a therapy’s inclusion on clinical pathways is more important than its coverage profile, but this isn’t always true. Across every oncology class, manufacturers need to know which organizations—IDNs, provider organizations, payers or PBMs—have the biggest positive and/or negative influence on their products’ utilization.
Patient access can easily be blocked by a misalignment between pathway placement and coverage requirements, without manufacturers realizing the disconnect. Simply tracking clinical pathways and coverage restrictions in isolation is not sufficient. Real-world data (RWD), especially claims data, can reveal a more nuanced picture of how access works in reality. How does the intersection of clinical pathways and coverage policies affect provider prescribing behavior? What about reimbursement after treatment?
- Why pathway placement matters
A drug’s inclusion or omission from clinical pathways is often a key factor in its utilization rates. Typically, an IDN’s clinical pathway is integrated into the electronic medical record (EMR) system physicians use throughout the day. If a manufacturer’s drug is not on the pathway, physicians may be unable to select it as an option for therapy.
- When pathway/policy misalignment impacts access
Notably, a drug’s inclusion on a clinical pathway does not necessarily mean that payers already cover it, or that medical exceptions will be automatically granted to providers. In some cases, payers and institutions vehemently disagree about what treatment is appropriate. Even if a policy and a pathway are developed by the same payer, they don’t always align, as they’re created by different departments with different intentions.
- How to leverage RWD with payers and IDNs
Manufacturers can use the insights they glean from RWD to proactively target the payers and institutions impeding patient access to their therapies. RWD can help manufacturers make a strong case for coverage directly to the payer. For example, if a manufacturer discovers that 40% of qualifying patients with a certain type of cancer are being treated at specialty organizations where their drug is on pathway, they have a better chance of persuading the payer to develop a policy for this sizable patient population.
In an increasingly complex marketplace, oncology manufacturers need a well-rounded understanding of how pathways and policies function during the treatment journey. Knowing which organizations hold the most power over their critical patient populations is the first step in an effective targeting plan.
Read the full article on BioPharma Dive. To see how IDN-level pathways data can inform your market access strategy, learn more about PULSE Analytics. Hear more about MMIT’s real-world data capabilities on this upcoming BioPharma Dive webinar, RWD: Overcoming the Chasm Between Payer Policy and Real-Life Practice.