Decision Resources Group Analysis of Formulary and Claims Reveals Diverse Market Response to Treatment Barriers

BURLINGTON, Mass., Sept. 25, 2019 /PRNewswire/ -- In today's era of rising drug prices and health insurance costs, a growing number of United States healthcare consumers appear to be at a disadvantage when it comes to obtaining and staying on the treatment that's best for them. This begs the question: what are drug manufacturers and insurance carriers doing to ensure patients can access their prescribed treatments? Analysis of claims and formulary data by Decision Resources Group (DRG) shows a variety of responses from the industry. The answer lies in diversifying pharma market access strategies.

The paradigm for market access strategy in the US has long been the negotiation between pharma and payers, in which pharma uses rebates to secure exclusive placement on formularies and aiming to reduce restrictions on drugs such as prior authorization requirements.

"Alternative strategies that involve varying levels of cost sharing and partnership between pharma, insurance carriers and pharmacy benefit managers (PBMs) are becoming more prevalent as drug costs rise," says Shruti Desai who analyzes drug prices and pharmacy benefit management trends at DRG. Two of the most common are:

1. Providing financial assistance directly to patients, primarily through drug coupons and copays (patient assistance programs).
2. Engaging in outcomes-based contracts where pharma bears partial financial risks if the drug does not perform as expected. 

According to DRG's real-world evidence from the migraine market, built primarily from juxtaposing formulary and claims data, treatment access is directly affected by these newer cost sharing approaches.

Migraine market access in the US
To capture the most accurate picture of the migraine patient's ability to access their prescribed treatment, DRG analyzed the full spectrum of pharmaceutical market access strategies for the newest and most novel class of drugs in the migraine market, CGRP inhibitors.

"When we considered conducting this analysis, the migraine market seemed like a perfect fit because of the high incidence, current level of development, recent launch activity, implications of comorbidities, and remaining unmet need," says David Raiford, Senior Director of Market Access Insights. "It's a competitive market, with both low and higher cost treatments available, so we were particularly interested in whether patients on high-deductible health plans (HDHPs) were able to access higher cost medications, because this would best indicate whether the couponing patient assistance program is having any affect."

Drug pricing data, formulary tiering, spending on patient assistance programs, and documented outcomes agreements were evaluated to determine the weight that the brands placed on each component of their market access strategies. Claims and covered lives data were used to determine if these strategies were effective in helping patients access the treatments (as indicated by share of market, and coupon usage on HDHP plans). This analysis was conducted within the commercially insured population.

"We can see based on this comparison that there isn't a single silver-bullet to ensuring optimum patient access anymore," says Tyler Dinwiddie, Principle Analyst, Claims Data Specialist. "These brands are heavily mixing their approaches to reach the right patients. Since market conditions are similar for many chronic conditions with high incidence rates, one could extrapolate the same findings will hold true elsewhere."

Key takeaways

Each of these three migraine brands is employing a diversified approach to patient access, and the evidence shows that the alternative strategies are influencing access, but there is significant room for further investment and collaboration between pharma, insurance carriers, and PBMs to make it easier for patients to access their prescribed treatments.

1. According to DRG's Fingertip Formulary data, all brands are using the traditional method of rebating to share the cost burden with payers in order to ensure favorable T1-T3 formulary placements for commercial plans (*Note that Drug Three has two unique formulations with different formulary tiering). Formulary data shows that over 50% of patients should currently be exposed to co-pays that range between $41-55.

2. For drugs one and three, outcomes-based agreements are slightly boosting uptake of favorable formulary placements (also indicated above), however according to actual out-of-pocket costs available in DRG claims data, there is still room to reach at least 20% of the prescribed population in these cases.

3.  Patient assistance programs, such as coupons and copays, are helping cost-vulnerable patients to access their treatments. However, there is significant room for pharma to invest further in awareness for these programs to make them more successful. This is illustrated by the percentage of claims filled through HDHPs that also include a patient utilizing a coupon program:

"We know we're looking at an industry that is struggling to come to terms with the cost to bring drugs to market, and the impact that will have on patient populations," says Sonali Prusty, who specializes in drug pricing and the pharmacy benefit market. "What we're seeing here is a slow shift toward greater cost distribution, and increasing reliance on new, diversified methods to make treatments more available to patients."

"By leveraging AI and machine learning paired with our platform of real-world data and industry leading insights, DRG can take a more holistic approach to combining and evaluating the wealth of market access data that's available to us today." said Vivek Sharma, CEO DRG.

To learn more about DRG technology solutions that enable this type of analysis, please visit the webpage: Coupon Analysis Threat Assessor

About Decision Resources Group
Decision Resources Group, a subsidiary of Piramal Enterprises Ltd., is uniquely positioned to help healthcare businesses improve the lives of patients around the world by creating patient-centric commercial strategies that drive better outcomes and better access. DRG helps clients propel commercial success with evidence-based business decisions by delivering expert consultation, data and analysis enhanced by machine learning artificial intelligence (AI). With collaborative experts spanning healthcare markets, disease areas, and data science disciplines, DRG clients have unprecedented access to the expertise, data and AI-technology solutions they need to anticipate customer needs, and generate new solutions to healthcare challenges. DRG's market access solutions give life sciences the most comprehensive view of patient access, and payer and health system dynamics at local levels for the global healthcare ecosystem.

Media contact:
Catherine Daniel
Decision Resources Group
212-414-7537
[email protected] 

SOURCE Decision Resources Group

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