How will the New Marketplace Affect Pharmaceutical Companies? Part 2

The Marketplace Effect on Pharmaceutical Companies

A Need for Vigilance and Readiness

New rules and compliance requirements will continue to evolve and change likely at a greater pace than commercial or other managed markets. This will require expanded vigilance and new tools to help track and work with these changes. There will be greater cost control and pricing negotiation expectations on pharma each year in this segment, with spill over potential to the broader commercial market. The Marketplace will become a significant component of the managed markets segment, with strong ties to Medicaid. This becomes an opportunity, with an estimated $26 billion in additional retail drug spend anticipated because of expanded coverage through 2021.

Tweak to Optimize the Opportunities

The out-of-pocket cap on medical costs across new insurance plans as stipulated by ACA is a significant opportunity for Pharma. This creates the following opportunities for Pharma:

  • Validation of currently subsidized patients who were uninsured, to make sure they are not in the Marketplace and thus qualified for benefit coverage (no longer in financial need of the subsidy).
  • Build Marketplace enrollment questions, guidance, and referral into the application process
  • Consider approving subsidies for a limited time, contingent on Marketplace enrollment

For specialty drugs, we anticipate that most insurers will require use of their specialty pharmacy network. Identifying patients through Pharma-specialty pharmacy relationships may become an efficient first step. Pharma will need to structure its research, clinical studies, contracting, marketing, and operations to meet these new stakeholder requirements and expectations.

Marketplace Bottom Line

In 2015 many insurers are looking to expand into new Marketplaces, and national insurers are planning to expand their footprints as well, due to very limited 2014 participation. Medicaid enrollment will continue to grow, particularly in those states that expanded the qualification limits. Those benefits, formularies, and pharmaceutical management approaches that are successful within the Marketplace plans in 2014-2015 will expand to become the norm across most of the commercial business.

 

 

How will the New Marketplace Affect Pharmaceutical Companies? Part 1

With the emergence of a new national health insurance Marketplace, insurance shopping has a new level of accessibility that has resulted in a broad-spectrum shift of health insurance operations, new insurers, formularies, and an array of benefits designed to meet the actuarial expectations stipulated by the law. As of April 19, 2014, over 8 million people signed up for a Marketplace plan, exceeding the projected 6 to 7 million, with an additional 6 to 7 million enrolled in Medicaid. The majority being previously uninsured. The Marketplace is poised to grow to over 24 million members by 2016 with the potential of expansion beyond that by tens of millions.

Formularies and Benefits in the Marketplace

There are approximately 250 formularies that have been created by over 275 insurers. While these formularies had to meet state specific essential health benefit standards, there is a similarity between the 2014 formularies and their commercial counterparts.

In addition, the Marketplace appears to take a more transparent approach to a number of circumstances where the drug benefit would not apply, including:

  • Out of network drug purchases do not count toward deductible or out of pocket maximum, or may have a substantially higher set of deductibles that apply.
  • Drugs prescribed by an out of network physician – not covered.
  • Brand drugs purchased when a generic is available – not covered.
  • Drugs that require prior authorization but are obtained without going through this process – not covered.
  • Non-formulary drugs – not covered.

Drug Utilization

Current Marketplace enrollees, tending to be lower income, overwhelmingly selected the lowest cost premium plans available. We would expect the same type of pharmaceutical purchasing behavior. An initial 2-month snapshot review of approx. 650,000 claims for 25 insurers from January to February 2014 by Express Scripts showed:

  • Higher antidepressant (8% higher), pain medication (29% higher), seizure medication (19%) use vs commercial
  • Specialty Meds: 1.1% of Rx vs 0.75% in commercial
  • HIV: 55% of specialty claims vs 21% in commercial
  • Cancer and HIV higher in Exchanges based on claim cost

Going forward, we would expect to see that initial skewing of drug utilization patterns begin to normalize.

The Marketplace:  What to expect in 2015 and in the Years Ahead

Insurer Expectations

Over the next 1 to 3 years, we expect to see greater market segmentation by key insurers. With some gaining hundreds of thousands of new Marketplace enrollees, this could stimulate new selective and targeted contracting interest and arrangements with Pharma. Insurers will drive toward value and lower costs in this transparent and competitive market, and will request this through contractual concessions and migration to shared risk/outcome type contracts from Pharma. Pharma will need to evaluate the traditional contracting value in light of the emerging reality in this market.

There may be a greater emphasis on certain classes of drug vs others. Products with a lower perceived value to the insurer (i.e., ones that don’t demonstrate cost reductions or quality of care improvements) may struggle to gain preferred status. Bundling such products in rebate agreements with other drugs that do have stronger perceived value is one way in which this risk could be mitigated.

The New Cost-Reactive Stakeholders

The member, with cooperation from their prescriber, becomes the key product decision maker relative to their ability to afford the copay (or coinsurance) at any tier level or the full cost through the deductible. Simply gaining a preferred brand position on a formulary may not return the contract value, as even preferred brand positioning often is associated with a significantly higher copay or coinsurance compared to generics (or compared to traditional commercial coverage of preferred brands (See table 1 above). Physicians will be interested in complying with their patient’s affordability expectation.

The Marketplace Formulary and Benefits

The formulary rules in place for 2014 will continue through the 2015 season (i.e., same benchmark plan, formulary Essential Health Benefits). There will likely be a change for 2016, but insurers are awaiting formal guidance from CMS which is expected to be issued by the end of 2014.

In our next post, we explore the effect on pharmaceutical companies and their business models.

 

 

Impacts of Healthcare Exchanges

Healthcare reform is bringing a major paradigm shift in the insurance market and the establishment of new healthcare exchanges. New legislation and regulatory standards are not only causing a surge in the number of people insured by commercial healthcare, but are also increasing the amount of Medicaid-covered individuals and the scope of Medicaid coverage itself. With the existence of a new national healthcare exchange marketplace and state-based exchanges, insurance shopping has a new level of accessibility that could potentially result in a board-spectrum shift of health insurance operations.

For pharmaceutical companies, this means a complete overhaul of existing standards and a forced adaptation to a new environment. Former costs, expenses, and policies will no longer function as they did, and healthcare companies need to guarantee their business and pricing models can exist in the new atmosphere. There’s no simple fix for those who decide to go it alone, but for industry-savvy executives, there are options to explore for making transitions quick and painless.

Exchange Enrollment

Continued enrollment growth in the healthcare exchange marketplace is driving the Affordable Healthcare Act forward. The open enrollment earlier this year caused a massive spike in the number of people insured in the United States, and the marketplace itself ushered in new insurance policies designed to provide coverage as required by the law. Since the penalty of fine is an ever-present deterrent from ignoring the new legislation, enrollment will continue until all citizens are covered either through commercial means or government programs. Charting enrollment progress and success can provide crucial insight into markets and customers across varying atmospheres and locations. As such, the practice allows medical companies to arm themselves with the knowledge of newly developing terrain in the healthcare landscape and use it to drive their own revenue and relevancy toward sustained growth.

The most important aspect of enrollment monitoring is casting a wide net. Since the new law affects change at the national and state levels, each state in the country will respond to and enforce change in differing ways, or at least at differing paces. As such, it is imperative to research how the market develops across the country on a state-by-state basis. Constant vigilance of the key players and major markets is the key to successful intelligence gathering that can stimulate growth and increase profit.

Never Stop Learning

Changes affected by new regulatory standards cause a need for new practices beyond market research. To fully understand the scope and impact of the Affordable Healthcare Act, education must be the primary focus. Tactical preparation for immediate changes and future shifts as a result of the initial impact provide a proactive way for addressing the new market. With workshops and seminars being made available to them, pharmaceutical executives must take advantage of resources that grant a deeper understanding of the issues and how to work around or with them.

Information is the best-suited tool for handling change. Not only is it necessary to understand and prepare for a new market, but the numbers generated by said market must be scrutinized and used to allow stronger brand identification and business strategy. Factual statistics regarding enrollment numbers, as well as Medicaid membership and impact, provide the basis for developing a marketing strategy. Education is essential to survival and any proposed system or strategy for addressing the new healthcare exchange market must be based upon informed decision making.

Full-Spectrum Coverage

The Exchanges360 suite provides comprehensive preparation for the shifting face of the healthcare industry. Through accurate, up-to-date data analysis, continued education through seminars and workshops, timely and frequent updates regarding enrollment statistics, and personalized consultation efforts toward strategy development, the package is the ultimate support for handling the new paradigm.

Daily on-going support ensures tactics never fall behind the current shape of the market, and direct consultation strategies keep businesses focused on the precise matters relevant to them while advancing new strategies for brand development and profit growth. Aptly named, the Exchanges360 suite provides full spectrum protection for pharmaceutical businesses against any and all unseen consequences of the implementation of the new healthcare market.

Alliance Reports Record Growth in 2013: Revenue Up More than 20 Percent Over 2012, 100 Percent Growth Since 2010, Continued Profitability

Alliance Life Sciences reports record revenues in 2013, and a three-year compound annual growth rate of over 20 percent that has led to revenues nearly doubling from 2010.

“Throughout 2013, we delivered a strong line-up of services and solutions which translate into over 20 percent growth for our third straight year,” says Alan Crowther, CEO, ALSCG. “Also, our addition of Jason Watters as an experienced industry chief financial officer will help lay the foundation for continued growth.”

Watters joined ALSCG after serving as chief financial officer at McKinsey’s IT Solutions division, where he oversaw part of that division’s growth from inception to almost $200 million in revenues in five years. He brings considerable experience in high-growth consulting and IT solution environments.

In addition, ALSCG had record bookings in December 2013 and January 2014, positioning the company for another record year in 2014.

Watters states, “Based on industry trends in Life Sciences, and the growing demand for our unique mix of services, we expect over 20 percent growth in 2014 and 2015. We forecast that the firm will have grown almost 200 percent since 2010 by the end of 2015.”

Not only is ALSCG growing revenues at a significant rate, but also the firm experienced a number of major successes:

  • Three of the Top 10 Pharmaceutical Companies adopted ALSCG’s PriceRight™ global pricing solutions
  • Four of the Top 10 Pharmaceutical Companies used or renewed ALSCG’s PRICENTRIC™ global pricing data services
  • Seven successful “go-lives” at clients with Revenue Contract Management suite implementations

Crowther adds, “Our tremendous success and growth in a short time reflects the strengths of our strategy, our close relationships with our customers, and the efforts of our professionals around the globe. Building upon this momentum, we will continue to offer customers the management, technology and software products they need to solve business problems, maximize revenue and achieve optimal pricing in an outcomes-based world.”

NJBIZ Ranks Alliance Life Sciences in Top 10 Among Technology Consultant Service Companies in New Jersey

Alliance Life Sciences has been ranked number eight among New Jersey’s technology consultant service companies by NJBIZ’s Annual Book of Lists 2014, an influential source of information for business-to-business professionals in New Jersey.

“This ranking reflects our continued growth, our record 2013 year, the quality of our employees and their dedicated approach to serving our customers,” says Alan Crowther, CEO, ALSCG.  “We are honored to be recognized by the highly respected and influential NJBIZ, and applaud their focus on critical business issues.”

ALSCG serves over 40 of the largest pharmaceutical and medical device companies, including 8 of the top-10 largest pharmaceutical manufacturers, enabling them to focus on continued investments in patient health and well-being by helping them receive fair value for their products with an integrated portfolio of services:

  • Management Consulting
  • Technology Integration
  • Solutions and Data Services

ALSCG has many specialized offerings with top strategic positions in the industry, and delivers these services with expertise across the following domains:

  • Global Pricing, Reimbursement and Market Access
  • Contract Strategy, Operations and Compliance
  • Commercial Operations and Analytics

Crowther adds, “ALSCG helps its customers maximize revenue and optimize pricing in an outcomes-based world. We employ hundreds of professionals around the globe who help firms obtain the best value for their critical healthcare initiatives. This distinction helps bring attention to our leading set of offerings and set the stage for our customers’, and our, continued success.”

Global Lifecycle Price Management – A 360 Degree Approach

When launching a new product, companies are often met with a series of challenges. Any error or miscalculation could end up costing your company a significant amount of market share. One of the biggest hurdles to overcome is pricing. Finding a price that is both competitive in the global market, as well as profitable, can be more difficult than companies realize. The key is having access to accurate and current prices of the competition, while at the same time being able to set and maintain effective prices with minimal manual upkeep. Another concern with global lifecycle price management is price erosion with products that have been on the market for a longer period of time.

For example, according to a study by the EPP (European Pricing Platform), 42% of organizations are operating on the most basic level pricing maturity. Approximately 48% are functioning on a higher level, having the right prices on the right products to the right people, but still aren’t fully integrating the commercial process of alignment with marketing and sales. While this second tier is more desirable than the first, it is still far from optimal.

Global lifecycle price management issues can typically be broken down in 3 subcategories.

Product Launch Challenges

These issues can be some of the toughest to deal with when launching a new product. An effective launch starts by determining the best country sequence in which to launch your product, where a mere 1% in price difference can end up costing millions of dollars in net present value, or NPV. Managing all the details and data for launch planning is also critical, especially in knowing the effect they have on pricing. Also, you must take into account the need for change as the project develops, and often times manage this with changing parameters, to keep pace with the project evolution.

Price Maintenance & Compliance Challenges

The next obstacle is maintaining the strength of products that are already on the market. As conditions change, so too must the price on a product. This helps to avoid price erosion, which can cost millions of dollars every year. Here you must also be able to quickly and accurately check reference prices, which is a crucial step in being able to set an effective price in any country. This is a highly effective way to protect your company from any errors in government price publications, as well as to assist in generating accurate reports.

Loss-Of-Exclusivity & Mature Products

When managing older products, the key is to be able to monitor and manage with minimal manual effort and resources. Once a product launch is successful to the point of near self-sufficiency, it’s time to move on to the next project. Having to divert resources to an old project means diverting time and energy away from new ventures, and this can be costly in the long run. Your business must be equipped with the right tools. Software that can efficiently predict the potential impact of price erosion means adjustments can be made before they end up becoming costly issues.

Prevention is Key

What it all comes down to is the proper amount of preparation. By planning ahead and exercising the proper caution and forethought, charting a course to success is easier than one might think.

In the study conducted by the EPP, 88% of organizations declared intention to invest in pricing software for reasons such as, price monitoring, reporting, price guidance and deal making. Alliance Life Sciences specializes in helping life sciences companies operate at peak efficiency with a full suite of global lifecycle price management software designed and developed to aid in managing your business and making sure you hit the right price for maximum profit.

For more information, an on-demand webinar is available on market access operational excellence. http://youtu.be/KEg55rrBfh0

Drug Costs: 5 Things You Need To Know

Recently Dr. Joel Owerbach, VP of Health Policy and Strategy for Alliance, was interviewed for WebMd’s Health Reform 101 blog on the new Health Insurance Marketplaces and Exchanges. In particular, the focus was around what they mean to consumers who are planning to purchase coverage on their own, and what they can expect in the process.

This piece provides a great 5-point summary on the new programs, and is both a quick-read and must-read for those attempting to better understand what they mean to the consumer. The full article can be viewed at this link.

One Week In

Welcome to our ALSCG Blog!

I am very excited to take the helm of Alliance Life Sciences and bring it together with the Adjility Health organization. It’s a privilege to serve both groups of employees, and all our customers.

Collectively, we have a lot to offer. We are solving complex problems across a lot of functions. We are doing great work in pricing, HEOR, contract management, clinical operations, and sales operations. We are introducing new algorithms to help our customers compete on analytics, we are creating some great technology and technology capabilities, and so on.

But what is most important in all of this is that we help our customers innovate in their work, and that we innovate in our own work. And by innovate, I mean real productivity gains and real shifts in ways of doing business. This is the source of real gain, this is how cash flow is freed up for the innovation that really matters: the research that brings new health therapies to market.

How do we show decision makers that a global trial can be executed for 3% – 5% less by optimizing site usage globally? How can a mobile app extend a pharmaceutical product into a service that has greater impact on patient outcomes?

We will spend time talking about how we are driving down the cost of our business and our customer’s business, helping manufacturers service patients and physicians better. Its not just solving a skill shortage or helping our clients with areas that are not core skills for them. Those things are nice – but we have to aim much higher, because the pressure to deliver on the industry has never been greater.

There are a lot of “first things” to get done, but one of the very first things we are doing is to get our leadership team up and active on all forms of social media, including our company blog. We have a very talented group with a lot of things to share.

Sharing these ideas with all of you, engaging in a dialogue with everyone more efficiently, is the first step in this process.

I look forward to what comes next!