Payer Access Special Feature 2021: Different, and yet the same

Different, and yet the same

As the grip of the pandemic eases, managed market executives on the pharma and agency side will have to modify their tactics with payers due to changed habits; at the same time, payers’ expectations of value remain strong.

By Christiane Truelove • [email protected]

A year ago, as everyone was working from home, no one knew quite exactly what the impact it would have on business practices. As more people are being vaccinated and many companies are issuing orders to return to the office, at least part time, the effect of COVID on interactions is lingering. For payers and pharma, in-person meetings have been replaced by online ones – and that is not expected to change. At the same time, payers are still seeking the same in-depth information on the clinical and economic value of pharma products, particularly important in the rare disease category, when the price of therapies are so steep. How can pharma – and its managed market agencies – meet payer client needs?

Payer stresses and strains

According to Roshawn Blunt, managing director of the managed markets agency 1798, a Fingerpaint company, payers are getting hit on all sides because of the pandemic, and marketers should be well aware of the environment. 

First to consider is what is happening to patients – the dramatic shifts of coverage caused by pandemic-related unemployment. Those who were covered under an employer’s insurance may now be using a plan under the Affordable Care Act, covered under Medicaid, or maybe not insured at all. 

“From a payer perspective, having to navigate those landscapes in certain areas, where you might see far more dramatic swings – for example, a diabetic population that may have been covered by commercial insurance may have to swing somewhere else to get coverage – means you’re going to be thinking about your economics in a fundamentally different way,” Blunt explains. “How you’re going to be negotiating with manufacturers and other efforts that you’re doing are going to, by extension, change.”

And the number of patients in employer-provided insurance plans versus the number of uninsured continues to change, Blunt says. “I think we’re going to be dealing with that for years. We thought we had it licked by bringing down unemployment, better than what it was with the Affordable Care Act, and now we really don’t know where things are going to go.”

Jill Lesiak, executive VP, executive creative director at Mosaic Group, an FCB Health Network company, also has noted the increase in managed care through Medicaid as a result of the pandemic. “We’re hearing from our clients, especially in certain categories, one in particular for HIV, that the states are starting to look more closely at their pharmacy and total budgets, and manage their budgets more tightly,” she told Med Ad News. “So we’re having to find new data, specific real world evidence that applies to that population, and put that into our communications, our value props, to make those stories more meaningful and more impactful.” 

Another stressor for payers is negotiating with their providers about what services are covered. “Everyone talks about telehealth and how wonderful that is, being able to access care in a safer and more convenient way,” Blunt says. “For some specialties it was a safety net, and it still was not necessarily covered. So the negotiations with providers, when you talk to the medical community, has also shifted significantly. What do they need to do to have an appropriate revenue level, to be able to treat patients, however they do it, whether through telehealth or being in the office? Those payer contractual negotiations have changed in the marketplace.”

A third stressor for payers is the impact of the pandemic on hospitals. “What you saw from some hospitals is if you’re in a better payer negotiation place and a better socioeconomic level, some hospitals did well even through the pandemic,” Blunt noted. “Others are closing.”

All of this means that for payers, all of their customers have gone through significant shifts and they have to rethink their strategy to make sure that they can provide the right access to beneficiaries. And that means anyone who is going into the payer market environment has to think differently when approaching them. 

“When you go in as a manufacturer to talk to them about a product, you need to be very aware of everything that they’re facing and the dynamics and strategies that they’re dealing with so you can try and bring something forward that [talks about] what is the value overall and how do you make this an appropriate alignment for what the payers are going through right now?” Blunt says. “We’re all in a tough situation, so how do we work this through to the benefit of everybody?”

One route was actually shown with some of the products being used to treat COVID, Blunt says. “More often as the dollars are going further, faster, it’s increasingly around real world evidence (RWE). Show me how this product is going to work in my patient population, and outside of the clinical trials,” she tells Med Ad News. “When the real world happens and things take place, and people don’t follow their medication regimen, and things blow up and you can’t see your doctor, all of these things have simply heightened the question from payers … of how your product works in real-world conditions.”

Manufacturers will not have that information at launch, but Blunt says even discussions around what a payer would like to see in the future, what will make them feel comfortable, and how the manufacturer can continue giving the payer information, has become a large part of the conversation with payers. 

Though patient-reported outcomes are not a large part of the discussions with U.S. payers about RWE, “it doesn’t necessarily have to be a hard Phase IV,” Blunt says. “That’s not necessarily where all the conversations go to.”

Whether the manufacturer chooses to do a retrospective analysis, a claims-based analysis, or an open-label study, they must be able to capture the data outside of the focused setting of a clinical trial, Blunt says. 

Adrian R. Garcia, who is senior VP, managed markets at Syneos Health, agrees that manufacturers have to have their RWE strategy figured out when talking to payers. “Gone are the days where you could enter a category, from a pharmaceutical standpoint with payers, and just have clinical data,” Garcia says. “[Payers] want to know what are they really going to expect to see in the marketplace. And if you don’t have it, what is your place to gather it?”

The new world 

In May 2021, Syneos Health Insights Hub released a survey on payer nonpersonal promotion. The survey of 17 pharmacy directors and eight medical directors, all responsible for decisions on medical and pharmacy benefits, found that nonpersonal communication will be critical since nearly half of payers do not anticipate in-person meetings for six to 12 months.

According to the survey results, payers have come to rely more heavily on search engines, digital platforms, and online medical journals, according to the survey results. In terms of how they would like information delivered to them, narrative email is the most favored format, with 50 percent of the respondents stating this preference. The least favored format was infographics, with 54 percent of respondents against it. And as far as whitepapers went, 56 percent were neutral towards them. 

Katherine Seay, executive VP, managing director of Syneos Health Managed Markets Communications, says one of the questions asked of payers was the desired frequency that they would have contact with their account managers moving forward. “The majority of them said quarterly. Another 25-35 percent said as needed. Kind of a, ‘Don’t call us, I’ll call you’ mindset. And there were some who said, maybe not at all. So we’ve got a pretty big percentage who are going to have somewhat limited to pretty limited contact with their account managers.”

Seay says, “We understand that we have to find other ways to reach them, whether that’s through email communications – we dug into what’s their preferred style of email communication. Is it paid search? Where are they searching on the internet? What kind of content do they want to engage in, if they are going to be surfing the web or using social media? What journals are they going to be looking at, if we were going to be doing journal ad placement? Are they visiting manufacturer websites more often?”

According to Garcia, one of the most surprising insights revealed by the survey is that there’s really no eagerness from payers to go back to the way things were before, pre-COVID, from an engagement standpoint. 

“There was always this routine kind of timeframe where you would talk or see somebody face to face, but a significant portion of the payers that we interviewed aren’t even looking to kick off in-person interactions again until mid-2022,” Garcia says. “It’s not that they don’t want to have the relationship, it’s just they believe it doesn’t have to be face to face.” 

Payers have become very comfortable with technologies, and even before COVID-19, payers were using video chat programs because so many payers and systems are nationwide, so they have to engage throughout the organization. 

“It’s really about how they get information to make the decisions they need to make as an organization,” Garcia says. 

The survey revealed that Google searching and search engine utilization are up significantly more than a year and a half ago. 

Another surprise was how many were getting information from a pharma-sponsored website.

“Typically, these payers would say they didn’t trust pharmaceutical websites, they wouldn’t trust the content,” Garcia told Med Ad News. “Generally, they’ve always had a bias. They always assumed that the pharma companies were trying to pull the wool over their eyes.”

This new reliance on search comes as payers have been away from the interactions that they have had with peers and colleagues. And Garcia believes this will not change. “Now a lot of them are back in the office but they’re not re-engaging with their peers and their colleagues the way that they used to, whether it’s internal or through associations. “

He says this presents a significant opportunity for pharma manufacturers to actually engage payers in this new behavior through nonpersonal promotion. 

“Most companies, they would always balk at our recommendations to do something nonpersonal, to do something digital, to do a payer-specific site,” Garcia says. “Historically, that might have made sense, as that just wasn’t what payers used or trusted. But I think this behavior and the data that we have shows that it may be time.” 

The key to engaging anyone, not just payers, in a non-personal way is by providing relevant information, Seay says.

“We asked about general things, and the thing that came out on top was information about new products,” Seay says. “Manufacturers want to know what’s coming down the pike, they want to be able to plan for new products, they want to be able to budget for them. So anything new product related.”

Payers also want to hear more about guideline changes, as they rely very heavily on medical association guidelines to determine whether to cover drugs in health plans, Seay told Med Ad News.

Another question that Syneos Health asked about: the top issues that payers are thinking about in 2021. The responses were COVID-19, vaccines and therapies; specialty pharmacy products; price increases; and gene therapies, which Seay says is new on the list. 

While many payers are still fully covering vaccines and testing, they are starting to eliminate the waivers that they had in place for COVID therapies such as Regeneron Pharmaceuticals’ Veklury. “Not every payer has done this yet, but some of the big ones have, and we’re seeing a trend in that direction,” Seay says. “It was a pretty deliberate decision, there was a lot of good will that came from waiving all of those fees associated with treatment for a period time, but they feel that we are in that leveling out phase where people have options to get vaccinated and other things, so they don’t have to bear that cost anymore.”

Gene therapy continues to be a topic of interest to payers for many reasons, Seay says. “Payers are still really eager to understand, when you have a curative type of an agent, how long are the effects going to last? Is it going to ensure for five years, for 10 years, for a lifetime, what exactly am I paying for here? They’re really demanding that information, to be able to cover these products.”

While alternative payment models have been proposed for these kinds of therapies, they are not easily implemented, Seay says, because they are difficult from a regulatory standpoint and a structural standpoint, as well as being difficult to implement and measure.

“We talk about them like they’re a great thing, and they can be, but they’re actually way harder to do, and I don’t think that’s been solved yet,” Seay says. 

With all of these concerns, Garcia says, “A really strong content strategy is what we’re recommending to clients. We don’t want to build a platform just to build a platform for payers, it has to make sense. You have to have the right content.” 

And having the right type of content is important. “It’s no different than in how you just can’t take an HCP piece and change the word ‘doctor’ to ‘payer’ and think that’s going to be relevant to them,” Garcia says. “You have to think about how they’re looking at their business, how they’re making decisions.”

For example, with gene and cell therapies, payers are not only concerned about the outcomes, they need to figure out how they can afford these therapies. 

“They want to deliver innovation, but you have to make them understand how they can deliver that innovation and manage that huge price tag.,” Garcia says. “So that content strategy is going to be critically important to help them determine how to communicate in a nonpersonal and a personal way. It’s just more challenging now because of the way that they’re engaging with account managers.”

As to what payers continue to look for, Garcia says they want a partner. “How you engage the payers and help them solve the problems that they have, is a really important way to establish yourself as a partner. They’re looking for pharmaceutical companies that can help them meet their objectives.”

Lesiak points out that most of the payer pieces Mosaic Group has been generating, and moving forward, are digital pieces such as interactive PDFs.

“But we’re also looking beyond those too, to other more innovative tactics such as considerations for payer websites, where payers can go and get on-demand content, whenever they want it, in their time and their space, as well as podcasts and other things like that,” Lesiak told Med Ad News. 

Innovation and RWE data

Greg Novello, executive VP, director of strategy at McCann Health Managed Markets, says payers will continue to have concerns about costs. But the pandemic also shined a light on innovation, science, and technology. “You couldn’t separate out what was happening during the pandemic, with innovation at a rapid pace with these vaccines, with these diagnostics, with treatments,” Novello told Med Ad News. “And I think the pharma companies who have been building up strong partnerships with their payer counterparts have been able to use that platform of innovation, science, and technology for their drugs, and the importance of that for their drugs.”

This is particularly true for gene therapies and rare diseases, where innovation is at such a rapid pace, he says. 

The pandemic has also heightened the importance of tracking the data as part of the quest for real-world evidence, Novello believes. “The data has become more important, as real-world evidence has become more important, and getting that evidence over time, to be able to bolster the value proposition of the drug and be able to prove the long-term evidence and sustainable outcomes of the drug.”

And in certain areas, such as rare disease, patient-reported outcomes may become more important Novello says. “Whereas typically, they may have not had great importance with payers, I think in the right therapeutic area, for the right disease states, rare disease being one of them, patient-reported outcomes can take on a heightened focus.” 

Another effect of the pandemic was the increased emphasis on real-time remote monitoring. For rare disease patients unable to go see their doctors, real-time monitoring provided a way for them to be able to track their condition. “And even when they were able to go back [to the doctor], in many cases, patients didn’t want to.” Novello says. “In many cases, real-time remote monitoring took on a heightened focus.”

Novello says things pharmaceutical companies could offer payers beyond the drug to manage certain patient populations could be support of remote patient monitoring and care management. For patients and providers, pharma can offer enhanced patient access and affordability programs. The latter is particularly important since many people lost their jobs and medical coverage. 

Some of the tactics Novello saw in use by pharma during the pandemic were virtual video and digital platforms. 

“I think a lot of it, the plane was being built when they were flying it,” he says. “The biggest thing was how do we engage beyond a telephone call, to be able to have a discussion and share information? And then how do we do that beyond just a one-on-one?” These technologies allowed pharma to involve multiple people, including outside experts to answer any questions that the payers had.

And not all of these technologies were being used during all phases of the pandemic, Novello points out. “When the pandemic first started, nobody at pharma was even talking to their customers,” he says. “But when they were mutually able to start to come together to discuss business, virtual advisory boards were another area, and I think the virtual advisory boards are an advantage, because it’s so difficult to get multiple stakeholders from payer organizations in a room together live. Being able to do it virtual, a lot of times you can do it quicker, and get the right people in the right room to have the right discussion in a productive and efficient manner. The technology can enhance the business at the right time.”

Lesiak also noted how many association meetings and conferences were switched to virtual, and though live meetings are starting to come back, the virtual meetings are here to stay. 

“And from a communications perspective, the meetings are also getting shorter,” she says. “People have less time. So it really challenges us as marketeers and communicators, to make pieces that are nimble and can be tailored to our customers’ needs.” Examples of this include value proposition stories that are navigable, so account directors can share the content that is pertinent to a specific customer.

Rare diseases and the pandemic

In any case, even in the pandemic, payers are expecting to see more from pharma companies as the number of entries in the rare disease therapy market increases, according to Raymond Johnson, senior VP of market access strategy at Ogilvy Health. “One of our immunology clients has been doing some market research and really thinking about access to these formulary decision makers,” Johnson told Med Ad News. “A common thought would be that given the pandemic, in-person visits would have been 30 or 40 percent of what they once were. But it seems as though the impact might not have been that severe across the board.”

The pandemic has made a change in how payers are obtaining the information that they need, Johnson says. For many HCPs, visits were extended through telehealth. “In the payer market, that channel for communicating clinical information for formulary decision makers, that telehealth alternative is evolving,” he says. That is going to be one of the key changes, and one of the things that our clients are asking for is more omnichannel type engagements.”

How do manufacturers convey and communicate and engage with these formulary decision makers, through non-personal means? What are the key channels and outlets? “One of the things that we’re doing is we’re looking to understand that,” Johnson says. “We’re still in the process of figuring that out.”

With the technologies out there and in-person conferences starting to come back, the engagement model as it was is evolving and it will be interesting to see which are going to be the channels that are going to be most effective and efficient at reaching formulary decision-makers. 

“But that being said, while communications with our formulary decision-makers are not able to be as promotional as our communications with HCPs or DTC commercials for patients, at the end of the day, our formulary decision-makers are people too,” Johnson says. “Some of the same places they go, such as social channels – there may be Facebook pages, there may be LinkedIn groups – so trying to think about different promotional challenges that may not be as mainstream today, will probably be more mainstream in six months to 24 months.”

Manufacturers also need to continue to evolve how they partner with organizations such as the Academy of Managed Care Pharmacy (AMCP). “The key is again not being promotional, but being objective, clinical, rational, with impactful information that is going to help the formulary decision-makers in discharging their tasks,” Johnson says. 

Rare diseases have their own challenges in collecting real world evidence, even without a pandemic. In primary therapeutic areas such as diabetes, the patient populations are large so information can be gathered from claims database reviews, and health economics and outcomes research (HEOR) studies can be undertaken. 

“I’m not going to say it’s easy, but there’s enough content to put together those retrospective studies to start to reinforce that what is achieved in the real world mirrors what was put forth in the clinical trials,” Johnson says. “With rare disease, it’s a little more difficult.”

Johnson says this is why in Ogilvy Health’s strategic launch planning, one of the keys is making sure the HEOR team and the medical team are integrated in that planning, allowing them to be proactive and thinking about how they can best glean the data early on. “It’s about being a bit more vigilant and a bit more purposeful in terms of trying to mine that real world evidence to support the claims. And it’s particularly important to think about in therapeutic areas where the cost of therapy is so expensive.”

The first therapy in the market, bolstered by real world evidence, sets a high bar, according to Johnson, so secondary or tertiary entrants will have to think long and hard about their pricing strategy as well as their clinical program in order to make any inroads.