Many manufacturers are interested in which factors can give them an edge on obtaining preferred coverage with payers. This is especially true given the increasing competition in saturated categories such as immunology, diabetes care and breast cancer.
We scoured recent MMIT research to gain a better grasp on the factors that are top of mind for payers—those that will truly move the needle in terms of coverage determination. Our findings show that payers consider three main factors when evaluating therapies:
- Cost minimization: In situations in which competing drugs have similar efficacies, like in immunology, payers report that rebating is a critical influencer for any agent to gain a preferred tier position with few restrictions. One MMIT panelist stated the importance of cost-minimization analysis for two similar types of interventions. While this analysis is only applicable for two or more drugs with similar efficacy and safety, it helps payers select the lowest-cost option. This analysis excludes patient preference, manufacturing partnerships and first-to-market drugs such as gene therapies, which could potentially reduce long-term healthcare cost savings with a high cost to be paid upfront.
Other types of pharmacoeconomic analysis leveraged by P&T committee members include cost-effectiveness analyses, which compare two different interventions—such as a drug vs. a diet program for treating obesity—and cost-benefit analyses, which are used to compare the total costs of programs, interventions, or therapies with multiple outcomes. However, these analyses require the costs and benefits to be expressed in the same terms, such that a monetary value must be attached to all possible outcomes.
- Star ratings: Medicare payers seem more open to covering products that aid in improving the health plan’s overall star ratings. Health plans are rated on a scale of one to five, with five being the highest, on more than 40 quality measures within five categories. Star ratings are essential, as they help patients objectively evaluate the quality of any Medicare health plan. Available plans are listed on the CMS’ Medicare plan finder tool based on these ratings.
MMIT research shows that payers track adherence very closely, as products with better adherence positively impact the star score. Moreover, factors such as non-compliance, reduction in hospitalizations and screening tests directly influence immediate healthcare costs, which also affect star ratings of Medicare plans. As a result, it could be beneficial for manufacturers to share any data analysis that shows overall healthcare cost savings.
For example, in a category like hemophilia, where less frequent dosing is highly appreciated by payers, one MMIT panelist noted the following: “Novo Nordisk’s Esperoct provides for an extending dosing option that would provide for greater patient control. … The drug retains favorable formulary coverage along with it being well-tolerated in clinical trials and real-world practice in providing prophylaxis coverage.”
- Meeting preferences: A third factor that’s important to payers is a logistical one: their specific preferences when it comes to meeting with manufacturers. Findings from MMIT’s Payer Message Monitor solution show that payers prefer to spend 15 to 25 minutes per therapeutic area, discussing at most two therapeutic areas per meeting. About 66% of payers report having between one to 10 meetings per month with pharmaceutical companies, with an inclination for fewer than five meetings if possible. In additional surveys, around 88% of payers report a preference to discuss no more than two therapeutic categories in one meeting with manufacturers. When asked about the ideal meeting length, about 53% of payers prefer 20 to 30 minutes, while the rest voted to meet for 40 to 60 minutes.
From cost minimization analyses to factors that influence star ratings to in-person meeting preferences, taking payer considerations into account is key for manufacturers looking to improve their formulary positioning and coverage, whether pre- or post-launch. Those that fail to understand what payers truly want will find themselves behind the pack in an increasingly competitive pharmaceutical marketplace.