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Trends That Matter: The Future of Value-Based Agreements

Posted by Dinesh Kabaleeswaran and Ritupriya Yamujala on Jun 4, 2020

The challenge of improving patient access while reducing treatment costs has led the healthcare sector to explore innovative contract arrangements. Using value-based agreements (also referred to as risk-sharing or outcomes-based contracts) biopharmaceutical manufacturers and payers agree to link coverage and reimbursement levels to a drug’s effectiveness and usage. These agreements have been a necessity in providing patients access to high-cost and high-value gene therapies. However, in chronic disease states like diabetes and cardiovascular disease, value-based contracts have been essential to managing treatment costs associated with the high-volume utilization of these treatments.

Current challenges in value-based care include stakeholders’ alignment on which metrics are measurable and are valuable to include in an agreement, along with the presence of extensive technology and an unbiased third-party administrator to track and report on treatment outcomes. Successful implementation of such programs also involves patient adherence to treatments coordinated and monitored by physician practices or hospital systems.
 
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Topics: Industry Trends, Market Access, Data & Analytics

Radar On Market Access: 1.7K Plans Apply for Trump Admin's Fixed-Insulin-Copay Program for Seniors

Posted by Leslie Small on Jun 4, 2020

The Trump administration on May 26 shared new details about a program that offers diabetic seniors access to a variety of insulin products for a maximum $35-per-month copay, AIS Health reported.

More than 88 health insurers offering about 1,750 standalone Medicare Part D Prescription Drug Plans and Medicare Advantage plans with prescription drug coverage have now applied to participate in the Part D Senior Savings Model, which CMS unveiled in mid-March. Medicare beneficiaries in all 50 states, the District of Columbia and Puerto Rico will be able to enroll in a participating plan during the Medicare open enrollment period that lasts from Oct. 15 to Dec. 7, 2020, for Part D coverage that begins on Jan. 1, 2021.

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Topics: Industry Trends, Data & Analytics, Provider, Payer

Radar On Market Access: Payers and PBMs May Play Key Role in COVID-19 Vaccine Rollout

Posted by Peter Johnson on Jun 2, 2020

The rollout of a vaccine for SARS-CoV-2, the virus that causes COVID-19, is an unprecedented logistical challenge. So will be deciding who gets it: experts say that the initial vaccine supply will not be large enough to dose everyone who wants it — and payers and PBMs will have a large role to play in distributing the medicine to the right people quickly.

David Simchi-Levi, Ph.D., a systems engineer who studies manufacturing and supply chain at MIT, tells AIS Health that it's inevitable that vaccine supply will not meet demand when it is available. "The question will be, who gets it?" he says.

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Topics: Industry Trends, Data & Analytics, Provider, Payer

MMIT Reality Check on Narcolepsy (May 2020)

Posted by Matt Breese on May 29, 2020

According to our recent payer coverage analysis for narcolepsy treatments, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

To help make sense of this new research, MMIT's team of experts analyzes the data and summarizes the key findings for you. The following are brief highlights. To read the full piece, including payer coverage, drug competition and prescriber trends, click here.

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Topics: Specialty, Market Access, Payer, Branding & Marketing

Perspectives on Surge of Mental Health Meds Use Amid COVID-19

Posted by Leslie Small on May 28, 2020

Newly released data from Express Scripts shows that the number of prescriptions filled per week for antidepressants, anti-anxiety and anti-insomnia medications combined jumped 21% between mid-February and mid-March — reaching a zenith during the week ending March 15, when the COVID-19 outbreak officially reached pandemic status. And analytics from UnitedHealth Group's OptumRx showed prescription increases of 15% for anti-anxiety medications, 14% for antidepressants and 5% for anti-insomnia medications during the month of March.

Industry consultants tell AIS Health that they're not at all surprised that the use of such medications is spiking. And they say that situation creates an urgent opportunity for companies that combine a health insurer with a PBM — like Express Scripts parent company Cigna Corp. and its peers — to leverage their unique insights into members' health.
 
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Topics: Industry Trends, Data & Analytics, Provider, Payer

Radar On Market Access: Will COVID-19 Advance Automatic Health Insurance Enrollment?

Posted by Leslie Small on May 28, 2020

As the COVID-19 pandemic continues to ravage the U.S. economy, it would seem to be the perfect time for policymakers to explore a policy option that has garnered rare bipartisan support: automatic health insurance enrollment.

"We have huge numbers of people who are losing employer-based coverage; most of them are eligible for some kind of help, but we know historically most laid-off workers do not enroll in coverage for which they qualify," Stan Dorn, director of the National Center for Coverage Innovation and senior fellow at Families USA, told AIS Health. "It's just overwhelming to be grappling with job loss and therefore it becomes imperative to make enrollment as easy, seamless and automatic as possible."

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Topics: Industry Trends, Data & Analytics, Provider, Payer

Radar On Market Access: COVID-19 Pandemic May Change Rx Delivery Permanently

Posted by Peter Johnson on May 26, 2020

Industry experts expect the COVID-19 pandemic and related economic crisis, in addition to the trend of vertical integration in the PBM sector, will increase those companies' direct interaction with consumers, AIS Health reported.

The recent wave of payer acquisitions of PBMs has kept the latter on strong footing despite the crisis. CVS Health Corp.'s Caremark, UnitedHealth Group's OptumRx and Cigna Corp.'s Express Scripts control approximately 74% of the market, according to a January 2020 estimate by Drug Channels Institute CEO Adam Fein, Ph.D.

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Topics: Industry Trends, Data & Analytics, Provider, Payer

MMIT Reality Check on Low Testosterone (May 2020)

Posted by Matt Breese on May 22, 2020

According to our recent payer coverage analysis for low testosterone treatments, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

To help make sense of this new research, MMIT's team of experts analyzes the data and summarizes the key findings for you. The following are brief highlights. To read the full piece, including payer coverage, drug competition and prescriber trends, click here.

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Topics: Specialty, Market Access, Payer, Branding & Marketing

Trends That Matter for Medical-Benefit Drug Spending

Posted by Peter Johnson on May 21, 2020

Spending on prescription drugs that are covered under the medical benefit increased by 65% between 2014 and 2018 for commercial insurers and 40% for Medicare, according to Magellan Rx Management's annual Medical Pharmacy Trend Report.

"The increase in medical pharmacy spend seems to largely be driven by inflation," Kristen Reimers, Magellan's senior vice president of specialty clinical solutions, tells AIS Health. "This can be a combination of two things, increasing costs of existing drugs and providers utilizing newer more expensive drugs. The pipeline was extremely robust and new therapies to market are contributing to inflation, driving the trend."
 
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Topics: Industry Trends, Market Access, Data & Analytics

Radar On Market Access: COVID-19 Pandemic Drives Home Infusion Utilization

Posted by Angela Maas on May 21, 2020

With numerous hospitals focused on the COVID-19 pandemic and many areas under stay-at-home mandates, home infusion is more important than ever. Changes within the industry already have been seen, and the current situation is likely to result in permanent shifts within the home infusion space, AIS Health reported.

"If you can do infusion at home, you need to do it there," maintains Ashraf Shehata, KPMG national sector leader for Healthcare & Life Sciences. "This is about controlling infection risk in the near term, and many home infusion candidates are in a high-risk category. Longer term, there has been a shift toward delivering care in the most economical and clinically appropriate setting, largely driven by payers."

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Topics: Industry Trends, Data & Analytics, Provider, Payer