Formulary guidance and transparency from P&T to point of care

Perspectives on Leveraging Payer Relationships

Posted by Matt Breese on Apr 12, 2016

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In the healthcare industry — as in life in general — time spent developing relationships pays dividends. At its core, a good relationship with a pharmacy benefits manager or payer that secures positive formulary positioning or easier prescribing access is no different than landing a new job or promotion based on a personal relationship you’ve nurtured over the years.

All relationships have three common elements:

  • Trust
  • Honesty
  • Integrity

Despite positive advancements in how payers, providers and pharmaceutical manufactures work together with a common purpose, many payers are still skeptical about their relationships with pharma. Questionable practices by a few, such as presenting partial or inaccurate data to back a new drug promotion or using ambush cold-call tactics to procure face time, do a disservice to all pharma stakeholders in search of truly valuable payer and provider partnerships.

Clear opportunity for improvement

A survey of payers gave pharma a very average 3.9 out of 7 when asked about their overall relationships with pharmaceutical companies. Unfortunately, any positive feelings about professionalism and recognized efforts to build relationships were offset by the use of questionable sales tactics, poor preparation and a general feeling that pharma representatives did not see payers’ needs as a priority. In fact, when asked how well payers felt pharmaceutical companies understood their needs, the score was even a little lower, 3.7 out of 7, indicating a distinct opportunity for improvement.

One survey respondent noted, “Most of the pharmaceutical companies I have dealings with are via appointment or by email or mail, and are very professional, knowledgeable and nice. Unfortunately, some of the representatives I have dealings with give their companies a bad name by turning up unannounced and are very ‘in your face.’ Others don’t know the answers to basic questions.”

So, where to focus?

Pharmaceutical companies can leverage relationships with payers to negotiate pricing, open doors to product advancement, prevent negative formulary changes or clinical edits on particular products, and impact market penetration. Relationships with the greatest potential are those with health systems that are also payers. In those instances, an effective pharma team can tap into the primal relationship between the payer and the health system and its providers to better address the needs of both the prescribers and the health plan.

A new day in relationship building

Not too long ago, pharmaceutical manufactures just had to prove their drugs were safe and effective. Today, their burden is still to demonstrate their drugs are safe, but also that they are effective compared to other products in their class and cost effective. The accurate portrayal of this information is critical to strengthening relationships and building trust with providers, hospitals and health systems, and payers. That trust can pay dividends for pharmaceutical companies.

The Affordable Care Act (ACA) embraces comparative effectiveness research as a means of ensuring quality, cost-effective care. For example, access to anonymous data (data that contains no traceable personal health information or PHI) can help companies create profiles of patients whose care is most significantly driving healthcare costs. In turn, they can use those profiles to support providers and hospitals in targeting of patients who potentially fit those profiles, and offer early and effective interventions that will improve their health, while reducing costs. This approach might be very effective with chronic conditions, such as diabetes, heart disease and obesity that have far reaching implications for a patient’s overall health and the cost of providing care, and that have multiple drug therapies.

This focus on comparative effectiveness is the new way of life in the healthcare industry. The advent of the ACA and related policy shifts in the United States, as well as austerity measures and legislation in Western Europe that promote pharma/payer relationships are fueling the pressure to generate data that will improve the quality of care and, at the same time, reduce costs. In the United Kingdom, the Health and Social Care Act of 2012 created a framework to explicitly promote collaboration between the National Health Service and pharmaceutical companies.

An emerging partnership with data

Not all partnerships are person to person. One of the key ingredients to success in today’s healthcare industry is the relationship payers, hospitals and providers, and pharmaceutical companies have with data.

Data acquisition is fundamental to analyzing the quality, efficacy and cost of healthcare. The introduction of value-based care (VBC) drives significant resource reallocations in hospitals and practices as organizations scramble to acquire, evaluate and leverage data across care management, information technology and analytics departments.

Moving from quantity to quality

Patients demand the best care with long-term results at a reasonable cost. Provider reimbursements, however, have traditionally focused on volume care — how many patients, tests, procedures. The shift from volume-based reimbursements to VBC, and quantifying quality, efficiency and cost takes C-suite involvement, physician engagement and a strong, mutually-respective relationship with pharmaceutical companies. On the patient side, resources and analytical tools with real-time data are critical to deliver quality outcomes and help patients avoid unnecessary medical bills. On the operational side, these same assets help administrators track cost trends, workflow, practice patterns, risk factors and demographics of their catchment area.

Pharmaceutical companies have a dual role in a data partnership. They provide data about their products to their clients to support prescribing practices, drug substitutions and formulary decisions — knowledge that gives both payers and providers an incredible tool to focus care on value, rather than volume. Pharmaceutical companies also use data internally to explore market- and service-growth opportunities. Data can help focus a sales force on credible new markets and identify gaps in service to existing clients.

Building relationships is an evolution. It takes time, leadership and integrity. In reality, it is the utmost logic that payers, providers and pharmaceutical companies become trusted partners with close-knit relationships. Ultimately, they are three entities that share a common goal — ensuring patient care delivers quality outcomes, while also fostering good stewardship of often limited fiscal resources.

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Topics: Industry Trends, Market Access, Payer