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Perspectives on Health Exchange Shifts

Posted by Matt Breese on Feb 7, 2017

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Over the past few quarters, the health insurance marketplace has evolved. The Affordable Care Act introduced health insurance exchanges (HIXs) to provide a market for health insurance to individuals who are not covered under employer or Medicare/Medicaid plans. While there are different schools of thought around these plans, many large payers and PBMs have pulled out of the segment. The number of lives covered under HIXs remains significantly lower than other channels.

Pharma, payers and providers must work together to improve value-based healthcare, including this new HIX ecosystem. In addition, pharma manufacturers need to determine how much to invest in contract and rebate strategies. 

The Shift from Volume to Value

Health insurance exchanges allow individuals to compare several health plans and select their preferred option based on the value, price, quality and benefits. For recent examples of health exchange shifts, view MMIT’s Reality Check on Respiratory (Asthma/COPD), one of our Top Market Access Posts from 2016. This report illustrates the changes by major disease area.

Pharma’s Role in Value-Based Care

Creating an effective healthcare system requires collaboration. In NEJM Catalyst, Thomas H. Lee, MD, MSc and Laura S. Kaiser provide four strategies for pharmaceutical companies to participate in value-based care:

  1. Pharma manufacturers can offer rebates based on a drug’s effectiveness
  2. A capitated or fixed rate per patient
  3. Greater collaboration with health systems in bringing drugs to market
  4. Joint analysis, with providers, of prescribing practices

In addition, accurate data is becoming increasingly critical for healthcare collaboration.

The Importance of Actionable Data Solutions

Technology encourages communication between healthcare organizations. MMIT provides actionable data to help pharma, payers and providers identify the best solutions.

According to Pierantonio Russo, MD, FAAP, FCPP:

“These changes are transforming, to some degree, the healthcare market to a retail market. In a retail market that requires communication directly to the consumer of the value proposition of services and products offered, data collection and analytics are essential to operate effectively and gain a competitive advantage.”


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Topics: Industry Trends, Market Access