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Perspectives on Simplifying Reimbursement Restrictions

Posted by Matt Breese on Apr 11, 2017

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In upcoming years, specialty drugs sales are expected to rise, accounting for nearly half of all drug sales in the US, according to HIT Consultant.  Specialty drugs typically require special handling, which makes these medications more expensive than other treatment options. As a result, payers use complex restrictions such as prior authorizations and step therapies (PA/ST) to reduce their costs. HCPs must apply for approval on an individual basis to get coverage for certain specialty drugs.

Pharma marketers can aid in the reimbursement process by reducing confusion around restrictions. Reps that have a comprehensive understanding of their brand’s restrictions can communicate them more clearly to prescribers. This shared understanding increases the likelihood HCPs will write prescriptions for their brand. 

Prior Authorization Policies

Specific requirements, such as prior authorization (PA) policies, make clinicians’ work more challenging. With these policies, HCPs must obtain approval from payers before prescribing certain medications, services or procedures.  The approval process is time-consuming and frequently delays patients from receiving treatment.

In fact, clinicians spend nearly 853 total hours per year on PA tasks, according to the American Medical Association (AMA). The AMA also revealed, “The time burden is so great that about one-third of physicians have staff members who work exclusively on prior-authorization duties.”

Step Therapy Challenges

In addition to PA policies, payers also use step therapy (ST) restrictions to control healthcare costs. In this case, payers require that patients try generic or lower-cost treatment options first before agreeing to cover the drug prescribed. According to PM360, “This process can sometimes take months to complete and over that time the patient’s condition may worsen and their responsiveness to therapy may diminish.”

When the process of prescribing a new drug seems complex, HCPs often fall back on their historical tendencies for prescribing. This behavior is problematic for new pharma brands that are aiming to increase their market share.

Communicating Brand Restrictions

As the industry focus on specialty drugs increases, brand teams need to better prepare for payer, HCP and patient responses in the increasingly restricted healthcare landscape. Peter Weissberg, Group Director at Intouch Solutions, recommended the following strategies for overcoming reimbursement restrictions.

  • Proactively communicate market access information to patients and clinicians
  • Display reimbursement information prominently on visual aids
  • Use market access teams for information on the reimbursement journey

Pharma companies must also educate their field sales team on market access to anticipate and mitigate risk. Here’s another marketing strategy, developed by MMIT, for communicating brand restrictions:

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MMIT Network’s promotional tools help simplify complex restrictions into normalized and consumable data points. To learn more pharma communication strategies, download MMIT'S Playbook: Simply Communicate Restrictions.



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Topics: Payer, Branding & Marketing