Managed Healthcare Executive - April 2009 - (Page 23) The balance of power is shifting to payers. With healthcare costs rising, payers are becoming the ultimate arbiters of pricing and value, reimbursement and prescribing decisions. Drug manufacturers will start thinking about product pricing earlier in the development, and in phase II, terminate any drug candidates that look unlikely to generate commercial demand. The often contentious relationship and competing agendas that have long existed among pharma companies, payers and providers will end as pay for performance and comparative-e ectiveness analysis force them to work together to improve health outcomes for the patient and demonstrate value. In the next 10 years, only drugs considered truly innovative will be nancially rewarded with a premium price. Pharma companies that choose to focus on specialized medicines will gradually shift their product mix to include more biologics and medicines that are targeted to speci c and more complex disease states. By 2020, new drugs will become more incremental. The blockbuster launch will be replaced by a process in which clinical outcomes information is continuously disseminated in a series of much smaller waves. national accounts managers from drug manufacturers, he says. On the other hand, Express Scripts also maintains certain principles in developing its formulary, which include allowing the prescribing physician to make the nal decision about a patient’s drug therapy and developing clinically sound formularies based on evaluations of independent physicians. Its approach includes review by therapeutic assessment, value assessment and P&T committees, whose members are not Express Scripts employees. Brand managers’ contact with the PBM has limited in uence, Neville says. EXECUTIVE VIEW PwC: number of U.S. sales reps nearly doubled to 100,000 between 1996-2005. Assn., says the closer relationship between MCOs and manufacturers is a result of the plethora of information now available for physicians, which was previously delivered by sales representatives. Now physicians, payers and patients have a variety of information sources. In addition, with the growing cost of drugs, Merritt believes that payers are more savvy about value-based drug bene t design so manufacturers have a greater incentive to interact with them. The interaction with health plans is all about establishing personal relationships and communicating the value a drug can bring to a health plan, believes Vogenberg. Pharmaceutical companies also are looking at di erent ways to reach the consumer directly, he adds. THE DRIVING MOTIVE Getting drugs on formulary is no longer the reps’ key motive; the emphasis is on reimbursement. Specialty products will deVogenberg says the focus has to be on mand a sales force with more the actual use of a product: whether it is clinical knowledge. being prescribed and dispensed. By 2020, more focus will be “Alignment of bene t design and acplaced on outcomes. cess to medications between managed care and drug manufacturers not only “We are not the decision makers, so can enable MCOs to better manage the there is little opportunity to in uence impact of plan design but also allows us,” he says. “Sales representatives do not manufacturers to make their products CHANGING THE TARGET have impact on value, and pointing out a more utilized,” he says. “If a product is In early 2008, several large drug manufac- clinical di erence is rarely enough.” available and there are no barriers to covturers explored the feasibility of assigning Joseph Sinopoli, founder of Prelaunch erage, then the issue is making ‘use’ hapdrug representatives to pharmacy bene t Strategy LLC, a consulting rm in Bos- pen, which creates product sales.” managers (PBMs) to convince them that ton, agrees that proving e ectiveness and Winston Wong, PharmD, associate their drugs are worth the price. The the- e cacy may be insu cient in swaying vice president, pharmacy management, ory was that MCOs pay for drugs, so they MCOs because if a drug is costly, it’s likely CareFirst BlueCross BlueShield in Baltishould be the marketing targets. They in going to remain on the third tier. In- more, says that the dynamics are changing turn can in uence doctors. stead, manufacturers need to prove that because of a con uence of factors—a lack Everett Neville, vice president of a drug has direct medical cost o set, put- of breakthrough products on the market, pharmaceutical strategy and contracting ting pharmacoeconomics front and center. the emergence of biologics and an emphaat Express Scripts, a PBM in St. Louis, In addition, he says, doctors do not decide sis on comparative e ectiveness. MHE says that the reluctance of physicians to if drugs need prior authorization or step schedule time with drug reps is also be- therapy, but insurers do. FOR MORE INSIGHT cause of new policies sti ing the visits. Mark Merritt, president and CEO of See more Pharmacy Best Practices on Express Scripts works with dedicated the Pharmaceutical Care Management managedhealthcareexecutive.com APRIL 2009 23 http://www.managedhealthcareexecutive.com
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