Staying Competitive in an Expanding Medicare Advantage Market
Over the past year, the health plan landscape has seen significant enrollment shifts, especially within government-sponsored plans. According to MMIT’s Directory of Health Plans, the top 10 Medicare Advantage insurers accounted for 77.2% of the national market at the close of 2022. Nine of the top 10 organizations reported year-over-year growth ranging from 2.8% to […]
The Problem with Copay Adjustment and Alternate Funding Programs
Payers’ use of copay adjustment programs has exploded over the past few years, and interest in them remains high. In addition, payers are now looking to bring down their drug spend by adopting newer strategies offered by companies with alternate funding programs. While many manufacturers are pushing back against these copay adjustment and specialty carve-out […]
The Evolution of Medical Benefit Contracting: How Pharma Can Prepare
Given the growth of specialty pharmaceuticals, manufacturers will need to develop more aggressive contracting strategies to secure optimal market access for their medical benefit drugs. Shifting market dynamics, driven in part by the influx of lower cost biosimilars on the pharmacy benefit, will require pharma companies to focus more on rebating and cost minimization. As […]
Market Access 101: Understanding the Basics
For many pharmaceutical companies, planning for commercialization only begins in earnest when a drug has been submitted for FDA approval—which is far too late. Ideally, a company’s commercial and market access teams should be fully functional long before the approval stage, as many decisions must be made in the early phases of the drug development […]
What’s Ahead for Market Access in 2023?
Despite the challenges of the pandemic, the pharma industry has enjoyed steady growth during the past two years, which is expected to continue in 2023. The global pharmaceutical market is forecast to expand at a CAGR of 5.7% between now and 2028. Hundreds of products are currently awaiting FDA approval, and new modalities, including cell […]
Accelerated Approval in Oncology: Why Manufacturers Need to Prove Their Worth in Timely Fashion
The FDA has created a number of pathways to bring drugs for serious conditions onto the market sooner than the traditional approval process would allow. These include priority review, accelerated approval, fast track and breakthrough therapy designations, as well as emergency use authorizations, which are used in emergency situations, such as the COVID-19 pandemic. One […]
What Role Do Social Determinants of Health Play in Market Access?
A patient’s journey to accessing life-saving therapies is rarely linear, and while much of that is due to factors within the healthcare system, many external influences are also at work. Social determinants of health are an example of these outside forces that play a crucial role in patient care, for better or for worse. Social […]
When Will Payers Improve Coverage of Prescription Digital Therapeutics?
At age 19, my stepson has run the gamut of therapeutic options—combination therapies, cognitive behavioral therapy, you name it—for treating his attention deficit hyperactivity disorder (ADHD). After 10 years of searching, we have yet to find a treatment that truly works for him. However, there’s one option that we haven’t tried: prescription digital therapeutics (PDTs). […]
Are Clinical Pathways Expanding Beyond Oncology?
In oncology, clinical pathways—recommendations of specific treatments for a specified group of patients—have long been used to help control costs and treatment variation while improving outcomes. Clinical pathways may be payer-driven or provider-driven based on the organization that develops and controls the pathways, and financial incentives and policing mechanisms encourage provider buy-in and adherence. While […]
What Manufacturers Need to Know About Alternative Payment Models
Much has been said about healthcare’s shift from a fee-for-service model to a value-based care (VBC) model—and for good reason. With 50% of clinical interventions resulting in unknown effectiveness, and 20-40% of health expenditure wasted on unproven or unnecessary treatments, VBC models can help reduce costs and inefficiencies for patients, providers and manufacturers. Yet while […]