What are payers focusing on in the time of stay-at-home, work-from-home, yet still trying to serve patients? What do manufacturers need to understand? Med Ad News spoke with Greg Novello, executive VP, strategy at McCann Health Managed Markets; Adrian Garcia, senior VP, managed markets, at GSW; and Katherine Seay, executive VP, managing director, managed markets communications, Syneos Health.
If you look at healthcare stakeholders in general, they’re really at the forefront of this public health response and they have different roles. And one of the things that’s very interesting is it’s kind of forcing them to integrate even more than they probably have had even in the past. Payers have to be doing more for their patients, and their patients have to know about it and their providers have to know. All of these stakeholders are coming together, and I’m not saying it’s this beautiful, integrated map, but each one of them has a role and those roles are intersecting with each other.
So when we look specifically at payers – this a very fluid situation and it certainly will evolve over time – there are three areas that they are focused on. The first is access to care, there is one thing that is COVID-specific, and I have that under more financial health, but in terms of access to care, they’re certainly giving greater access for any COVID testing, any COVID treatments, for any COVID hospitalizations, or even medications that are off label that they may take. Most plans are doing that at no charge to the patient. They’ll be waiving co-pays, as an example, or the patient out-of-pocket or patient cost sharing. Most plans are waiving that because they know they need to do their part to help.
But it goes beyond just COVID-19. If you think about just a general disruption to healthcare because of COVID-19, there are lot of patients who don’t have COVID, but because of the disruption to the whole healthcare system, the priorities are focused more on COVID than routine care and it can make it a barrier or harder for patients to get access to medication – think of chronic conditions as an example. Folks who are dealing with diabetes or cardiovascular conditions. So what they are doing, and this is a general statement, it depends on the plan, the therapeutic area, and the drug, but a lot of times they may be extending existing authorizations, such as a specialty product that needs a prior authorization every six months for example. They may extend it knowing that it’s going to be a burden on the system [to obtain authorizations] because now the provider has to get involved in it to get another authorization to the payer and get that prescription authorized again. So some plans are tending to that for certain therapeutic areas and certain drugs. It takes the strain off of the provider and the patient having to go through that and make it easier for the access to the medication.
If you look at a lot of these chronic meds, a lot of them have refill authorizations, you have a certain number of limits for what you can get. A lot of times you have to wait to get a refill until you’ve gotten past a certain point in taking your medication. They usually track that by number of days. A lot of plans are relaxing those refill requirements, so you can get a refill much earlier in the process. They can get medication earlier so there’s way less of a chance of them having a lapse in treatment.
The third thing is, instead of 30-day supplies, they [plans] are encouraging patients to get 90-day supplies, either through mail order or potentially through retail, to ensure that they have treatment when they need a treatment and hopefully minimize any disruptions of being able to get treatment in this crisis.
Another one is expanding coverage through telemedicine. If it’s COVID-related, most plans are saying, hey patients, you don’t have to pay anything. But also expanding coverage for the patients to be able to use telemedicine. Some plans might not have full coverage on telemedicine depending on the benefit plan. So it’s expanding the telemedicine coverage for the patient so that they have access to it, and they can be covered for it financially. If they are using telemedicine for something different than COVID they would have to pay a co-pay, but the whole idea is, ‘How do we created better coverage for telemedicine for patients so that during this crisis, they can use telemedicine from home and not have to go out.’ So they’re broadening it so that patients can have access to doctors and access to care.
There’s also proactive outreach to at-risk members. Plans have case managers, and their job is to reach out to at-risk patients – those patients who can be the elderly, who typically have serious conditions or comorbid conditions. They reach out, in addition to the physician, to make sure that they are doing OK, that they are following their treatment regimens, a lot of other times they’ll go into dietary needs or other things that can help these patients manage their condition overall so that they are doing better and have fewer events, if you will. So case managers are looking at at-risk members, and reaching out to them, because in this time of COVID, it’s a crisis, but a lot of these at-risk members could be at risk for COVID. They’re looking at comorbidities, behavioral health’s a thing now, with people stuck in the house and the fear and panic they may have. So they’re doing their part, to reach out to at-risk members, from a care management perspective.
The next one, they’re a business they have to stay financially healthy over time, so they are focusing on their own financial health. There is going to be an impact on their revenue. People are going to lose their jobs and what happens when people become unemployed you’re either going to have a loss of insurance for that patient or that patient may go to the state market exchanges or that patient may become a candidate for Medicaid because their income level has gone down so much. So payers are going to have less revenue and less insurance coverage for members because of that. Then on top of that, you have the medical expenses increase, as many plans are picking up the cost of COVID-19 related expenditures, so that obviously is going to be hitting their pocket. And then the other part is employer pressure. As employers see their businesses significantly impacted, that puts pressure on them to put pressure back on the health plan in terms of what they’re contracted and what they’re paying as insurance coverage for their employees. They are going to want price concessions or even deferred payments.
And then the third one is this kind of business continuity, just trying to keep things going. A lot of people are working remotely, and meanwhile they are trying to keep things running as normal and sustainable as possible.
The pharmacy and therapeutic reviewers, because of all of the disruption and you have people working remotely, it’ll create disruptions to that whole P&T process and also may delay some formal formulary reviews for products or classes of medication in general. But one payer may say, give it access for now. A lot of these are ‘mays’ right now.
Some of the things pharma can do, one is empower payer teams to call on insurance plans and appropriately engage. The approach that pharma takes, the tone that they use, becomes really important because there’s a bigger thing going on than just selling their drug. Some companies are saying right now, ‘Don’t engage with your payers proactively. Do it reactively. Because we don’t want to burden them with stuff. They have other priorities and focuses, and we shouldn’t be going to them right now, let them do what they’ve got to do.’
And we talk about proactive partnership and support in communication. There have been some companies who sent out communications saying that these are unprecedented times and very challenging and they were there to support. It’s not the typical, ‘Hey look at the benefits of our drugs.’
Some of the things that become important, we’ve heard a lot about [pharma] supply chain updates. Payers wanting to know, or sometimes pharma companies proactively saying, ‘We have plenty of drug and throughout the supply chain it is available.’ So that they have confidence that the doctors and patients can get the medications.
And we’re hearing about pharma offering virtual resources as well, because everything has to be done through virtual and digital, there’s no live calling on anyone. But you have to have that first step, it has to be done in a partnership-type approach. It has to be done with the right tone and with empathy.
Adrian Garcia and Katherine Seay
Katherine Seay: Like anything else, the manufacturers are going to have to meet payers where they are, and how all of these things are impacting the payer and what will be most valuable to them at this moment in time. A few of the things that we thought were important for manufacturers to understand right out of the gate is how is this impacting the way that payers are working? What we found is that for the national and regional health plans, it’s really sort of business as usual, and they are moving forward and they are evaluating and assessing things in real time, they are making decisions as they would. Even formulary decisions, their P&T meetings, they are moving ahead with decisions for 2021 and beyond. So it’s really important that the manufacturers at this point in time don’t take their foot off the gas. If they have products that are in the pipeline and are expected to launch sometime in the near term, or if they have a significant label update coming, it’s really important to payers. Even for products already on the market or mature products, it’s important that manufacturers cut through the noise to the best of their ability and continue to deliver value-based messaging for their products to payers, again understanding that they are going to be moving forward with decision making.
In contrast to that, we’ve got the IDNs, which are often acting as the payer and the provider. Of course at this time where they’re preparing for and treating patients with COVID-19, there is more of an emphasis on the provider portion of their model. Most of their energy and effort is going into scenario planning and being prepared to treat patients to the best of their abilities. They’re not moving forward as much as the health plans are with regard in normal day-to-day business.
Adrian Garcia: The idea of keeping your foot on the gas is important not just from a short-term standpoint. We really don’t know the impact that this pandemic will have on payers and their budget responsibilities, short term and longer term. So there is a potential chance for payers to start to look at categories that they may not normally look at to find places to save money. We know that there is going to be an increase in spending – hospitals, payers, plans – and they’re all going to have an increase in expenditures, due to the pandemic. And as a result, the knee-jerk reaction could be for a plan to look at places where they might be able to constrict, to manage their margin a little more effectively. So there are potential categories like chronic conditions that have high spend, where payers can look to that space and say, “Hey, maybe we need to make a decision here, as a result of the pandemic,” and become more restrictive. So that whole concept of keeping your foot on the gas is critical, not just for products that are relevant to the patient experiencing COVID-19, but just in general of that healthcare spend overall.
You’ve seen the health plans react to help the everyday population as well, not just those suffering from the pandemic. That’s why you’ve seen a lot of payers remove their copay requirements, to make sure patients have no excuses to stop their medication. They want to maintain the environment as much as they can.
Manufacturers have a real opportunity, through the health plans, to reinforce the types of solutions, the type of tools that they can bring to bear to help patients stay on therapy at a time when not only the pandemic is causing us not to go out more, but also causing a lot of unemployment. The financial situation creates an opportunity for patients to ration their products, or stop taking their chronic medications, and that’s a disaster for everybody. Those long-term effects are something that the health plans are looking for help from the manufacturers to avoid, through their co-pay programs, through their reimbursement programs, through their customer support programs. You’ve even seen some large companies in the diabetes space, for example, they’ve delivered different ways to get medications to patients who have lost their jobs and I think you’ll see more of those over the next several weeks to help patients stay on medications long term. It’s not directly related to COVID-19, but it’s directly related to the fallout of COVID-19.
Katherine Seay: It’s really going to be important that manufacturers keep an eye out on those patient affordability programs, there will be a pretty significant increase in utilization of those. And actually, we were starting to see publications in mid-March even that there has been an increase in the use of savings cards. And even for those patients who still have employment and still have insurance, there is a cost sensitivity now. Of course the loss of jobs and the loss of healthcare coverage are going to be big reasons why there is greater utilization of patient assistance programs. But even with the co-pay cards, there will be more people using the full-cost buydown where manufacturers will be paying a bigger part of the patient’s cost share. Manufacturers will need to keep an eye on their programs to make sure they’re meeting not only the needs of patients, but not negatively impacting their own margins.
Adrian Garcia: [About conducting a launch aimed a managed care audience] Not only do you have the challenge of COVID-19 going on, you have the challenge of some people working in a completely different manner than what they’d normally be working in. Some of the insights we gained is now how limited the whole organization is in getting information when they’re trying to make a decision. It’s not that payers aren’t used to working remotely, especially the large health plans. Our data show that they’re used to this, and they’re telling manufacturers that they have to train their account managers to use this type of technology. They’ve been living this way, we all know that health plans are national organizations and even the regional ones are spread out. Pharma, on the other hand, is so used to face-to-face interactions or over the phone interactions, or one on one interactions. The manufacturer needs to ensure that the content that they normally deliver in that face-to-face interaction or that one-to-one interaction is optimized from a technology standpoint.
If you’re going to be launching something, think about the amount of information, the content that has to be shared to help the payer understand where the opportunity is, how this product delivers value, and what the clinical impact is and the economic impact is. A lot of those tools are very different, a lot of guess, if you will. Our job is to help our client make that concept less dense and more digestible, but not only do you have to think about the concept but how it’s being communicated, what the medium is, what the channel is. We’ve all had challenges with technology, not one of us is immune to that. So how are you building you content for what you think is happening but may be happening as well, especially important if you’re trying to launch, or if you’ve already launched and are trying to gain access.
Katherine Seay: Another way payers get information is through conferences. And all of the conferences have been canceled as of recently. And they rely on these conferences for a number of things. This is where they interact with colleagues, get updates on new products and new technologies. There are a lot of inputs that are available to them at these types of conferences, but that in many cases has gone away. And so they are actually looking now for more opportunities to engage with their peers, to engage with thought leaders, KOLs in specific therapeutics areas. They’re looking for input for data. So this is an opportunity, in our minds, to use some of these great technologies and platforms to create some of those interactions with payers that they’re missing at their conferences.
Our survey really asked what are the top recent changes impacting payers and tied for number one was canceled conventions. So this is something really on their minds and they’re looking for new ways to engage. And that to our minds seems to be a nice opportunity as well through these virtual platforms to give some of those opportunities back.
Adrian Garcia: Anything that the manufacturers can do to help create an experience for those payers missing Asendia, missing ASCO, will help them communicate their value story. They’re looking for help, the associations are looking for help. Anything the manufacturers can do to help disseminate information, even if it’s not a launch, is critical.