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

Perspectives on Managed Care Strategies

Posted by Matt Breese on Feb 2, 2016

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From P&T to point of care, many industry experts debate the future direction of managed care. Managed care plans focus on reducing cost while improving the quality of care for patients. However, it seems that many recent strategies focus on either one side of the equation or the other. As 2016 moves forward, pharmaceutical manufacturers and payers invest in optimizing their managed care strategy and driving value for their networks.

A Chance to Learn: Increasing Quality, Reducing Cost

Dr. Bill Mayer, CEO of The Federation, “wants to help the six not-for-profit health systems that have joined to form a clinically integrated network,” and the benefits of this integration are impressive.  Through this formation, stakeholders share clinical best practices among each other, with the goal of improving the quality of their care.  The Federation provides an environment that allows participants to “reduce costs to remain competitive [as they] prepare for risk-based payment models.”  This collective is one example of a managed care effort that could drive massive benefits for the industry through the promotion of education and interconnectedness.

The prevalence of integrated networks and general consolidation within the payer industry represents a significant opportunity for pharmaceutical manufacturers. Through strategic relationships with networks like The Federation, pharma can drive more efficient managed care drug penetration, specifically when clinical value is present. For payers, combining forces with other industry stakeholders aligns to the core struts of the healthcare reform and offers an avenue to streamline areas like P&T operations.  

The Next Generation of Managed Care

The launch of a new program, called the Next Generation, could provide Accountable Care Organizations with more traction in the industry and solidify their presence, as a result of the Affordable Care Act. “Loaded with new tools, beefed up benefits for providers and beneficiaries, and a capitation option in 2017,” Next Generation offers participating organizations an entirely new incubation landscape. The program supports the modernization of payer and provider workflows and presents great potential for the entire healthcare network if implemented correctly. In a setting dominated by regulation and oversight, similar initiatives provide a more 21st century mindset to leading payers and providers in the managed care space.

New Opportunities, New Challenges

With a number of changes to the pharmaceutical and healthcare landscape, America’s Health Insurance Plans (AHIP) faces some tough challenges in 2016. “Over 60% of all Medicaid in [the] country is now delivered through managed-care plans,” presenting new complexities and opportunities for solution providers. For organizations like AHIP, Medicaid managed care requires a thoughtful and targeted strategy in each state. In the same thought, understanding the managed care coverage landscape and how payer stakeholders influence the marketplace is a critical activity for pharma. For certain therapeutic areas, like PCSK9 inhibitors, managed care access can significantly impact the overall utilization of a product during launch and throughout a drug’s lifecycle.

Managed care faces significant hurdles that require thoughtful and continual debate in 2016. For payers, manufacturers and providers, the development of executable strategies is essential for success in managed care. While the landscape provides new challenges, it also presents opportunities for new solutions in the space.

Stay tuned for more developments on how shifts in managed care access affects specific therapeutic classes.

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Topics: Industry Trends, Market Access, Payer