Building an evidence-driven framework for greater access

Cost-effectiveness will influence coverage to a greater extent

While 66 percent of health system respondents said that a drug's clinical profile is the biggest influencer in coverage and placement today, 78 percent of respondents believe that in the next five years, cost-effectiveness could grow in importance for formulary decision-making.

Competitive dynamics are playing a bigger role in review decisions

Payers are using increasing competition within classes to revisit past decisions and get more benefits from manufacturers. 58 percent of health plan respondents reported competitor pricing and contracting strategies commonly trigger drug reviews for coverage and placement, compared with 44 percent of health systems respondents.

Decision-makers want to see much more data before launch

Interviewees stressed the need for access to more transparent and factual product data as early as possible in the development cycle–which could go a long way in enabling better planning and budgeting to help ensure patient access to new therapies.

RWD could increasingly complement clinical trial data for access decision-making

There is a growing interest among organizations to look beyond data collected during clinical trials for access decision-making. Many large health systems and health plans are already collecting patient-reported outcomes or analyzing their own patient or member data to create evidence-driven protocols.

Decision-makers expect value-based contracting to increase 

To address uncertainty around value, health plans and health systems believe value-based contracts that allow them to share risk with manufacturers are useful. 66 percent of survey respondents expect use of value-based contracting to grow in the next five years.

Few organizations are building capabilities to leverage RWD and value-based contracting, presenting opportunities for biopharma

There is an opportunity for biopharma to collaborate with health plans and systems to build tools to leverage the increasing volume of patient data for decision-making. While most organizations see the potential of RWD and value-based contracting to aid decision-makers, few are investing to build internal capabilities to harness these for formulary design and cost containment.

Our research demonstrates that it is now more critical than ever for biopharma companies to rethink the way they approach and communicate product value to access decision-makers. Our research also helped us identify steps biopharma companies should consider when crafting a compelling value proposition for their products:

Engage early: Prelaunching information exchange can help pharma companies engage with access stakeholders prior to launch.

Understand value drivers: Identifying or defining value drivers unique to individual payers and providers and understanding how these are assessed could help develop an intimate understanding of how key customers define value from therapies.

Align evidence generation plans with value drivers: There is a need to incorporate US access stakeholder value drivers into global evidence generation plans. Cross-functional alignment on the desired value claims, proof points, and approaches to address priority evidence gaps can help achieve this.

Craft customized value stories: Pharma companies should craft customized value stories that resonate with access stakeholders’ definition of value. Such stories should incorporate clinical, economic, and humanistic perspectives on product value that adequately reflect pricing.

Be more data-driven: Sustained investments in analytics will power risk-based value modeling, identifying target reimbursable patient population and other analyses to build customized value stories.

Be transparent: The health plan decision-makers we interviewed indicated that they are more interested in draft models with transparent parameters and assumptions provided by pharma companies than black-box budget impact models.

Collaborate more: Pharma companies could enter into strategic partnerships with payers and providers to exchange data and build tools to map the patient journey and generate RWE.