With continued cost containment efforts, the pricing and reimbursement environment in every market just gets tougher every year.
Drug budgets shrink – and this in turn tightens access requirements. Regulations are getting tighter, so you need to ensure your market access strategy is a winning one. Each market is different but the world roughly breaks down into 4 approaches – therapeutic referencing (e.g. Europe and Japan), competitive insurance models (US), health economic driven systems (e.g. Australia, Canada, UK), and emerging cash systems (e.g. China).
Payers are even more critically important stakeholders for your strategy than ever before in every one of these models. Is your market access strategy fully in tune with your payers and their drivers? If you are not sure, keep reading.
How do you understand your payers’ needs and real drivers?
The basis for payer decisions is not always transparent to Pharma. You assume it is the obvious things – like cost. How do you find out? Ask the payer KOLs? Well, assuming they tell you, it is not quite that simple to uncover a driver. If you ask them, they may say ‘cost’ or ‘value’ or ‘patient outcomes’ is the key driver, just like physicians in US will say ‘efficacy’, and physicians in Japan will say ‘safety’ and ‘minimal side effects’. Of course, these are all important, but are not always the only drivers.
Saving huge costs means nothing if the drug doesn’t confer a compelling clinical benefit. Also, some of these are difficult to define. For example: what is ‘value’ in this definition? What is ‘patient outcomes’? ‘Progression-free survival’ is an attribute we have used in many Oncology marketing analytics projects and one could be forgiven in assuming that it is a patient outcome, but payers often dispute its value as an outcome. To get to the underlying real drivers and behavior changers, you need an intimate understanding of the key drivers (real and not just stated drivers) for each stakeholder group, and have an appropriate cohesive strategy for each segment. You also need to know what will make them consider a drug positively and grant it favorable pricing and market access.
Payers are people, and people have a complex combination of rational and emotional factors for their behavior as has been highlighted in many studies. We know we cannot ask them directly so we need to mathematically figure it out. As Henry Ford once said, “If I had asked people what they wanted, they would have said faster horses.” As data scientists, we need to ask insightful questions and then mathematically figure out what the answers actually mean for real world behavior. That is the basis of our analytics and should be the basis of how you are also going about this process of getting to the drivers.
How to ensure good access
In order to gain strong access, the following questions need to be examined:
• Do I have a clear understanding of the decision-making process of the payers?
• Do I know what the real drivers are (not just stated but mathematically determined)?
• Does my methodology simply ask payers questions to provide their view of the answer, or does it actually figure these things out mathematically using current customer-data?
• Do I know which of these drivers will yield the strongest impact?
• How much impact would that driver give me?
• Can I do reliable data-driven scenario planning to see impact of different marketing strategies on access?
All Pharma deploy market access teams to engage the payers and assist with these challenges. However, for them to be effective, we really must be sure that their strategy for these interactions is sound. In order to be able to do that, we need to understand the needs and real behavioral drivers (not just stated) of the key market access stakeholders involved at each stage of development and commercialization as the needs may change. It is critical to ensure that you position your product in alignment with payer drivers and market it appropriately to those groups.
In the US, drug launch criteria for access tends not to vary by class (with the exception of Oncology… but that is changing) but can vary positively (e.g. if the drug treats a condition with a highly vocal advocacy group that are pressuring them, or if it meets a high priority unmet need e.g. Gleevec) or negatively (e.g. if the drug has significantly higher cost with little efficacy/side-effect/safety improvement), depending on the situation.
