Patient Access: Getting to YES

Mapping needs and high impact solutions Establishing mutuality and securing commitment

Patient Access: Getting to YESDriving Patient Outcomes

http://bit.ly/1QKERpj

Market Access is about getting Payers to say yes, when no is the easy option. This white paper explores the components of getting to yes and some simple

guidelines for helping Payers see why saying no might be the easy option but it is not in their best long-term interests.

Driving Patient Access

Driving Patient AccessA Sustainable Rationale for “YES”

Payer Archetypes

have Rx choices

Show Performance vs SoC

(Value and Cost)

Access: creating

the“YES”


To achieve this, Pharma needs to:

• Demonstrate understanding of the issues around an SoC

• Know the key players and be aligned with their priorities

• Help build and install pragmatic, high impact solutions to drive improved KPIs and outcomes

• Commit to bi-party MEAF which require the commitment of both parties

• Track how a new SoC has delivered better healthcare outcomes

Driving Access – Driving Outcomes

…and needs to be leading the Payer solution.Pharma needs to be a partner not a vendor…


Understand Funding Flow

Map Inefficiency

Integrate Into

Agreement

Identify High Impact

Interventions

Driving Outcomes - A Staged Mechanic for Building Mutual Success


Understand funding flow

Map inefficiency

Integrate into

agreement

Identify high impact

interventions

A partnership must be built around mutual benefit.Many healthcare environments are complicated. The first step in understanding where a therapy might add value is to know what value means for the provider – this will typically be found in what they measure.

Key questions in this phase are:

• What are the KPIs?• What are the issues?

Facilitated discussions with key and representative stakeholders will allow both sides to understand the stakeholders’ objectives and how these can be translated into measures and KPIs.

Mapping Inefficiency

Key outcomes from this process:• Clear background to the therapy in terms of issues and the measures

historically employed• A matrix of measures and KPIs that are understood (even if not

employed) by the various stakeholders• A clear representation of the issues felt by the stakeholders• A summary of how this will drive activity in the next phase


Where does a therapy impact?

• Provides scalable mechanics to map the KPIs and Disease Management KPIs for different disease areas and align these with each Payer Archetype

• A Payer Archetype framework will support this process by identifying all levels of stakeholder and facilitating an understanding of their likely KPIs

• All aspects of performance (financial, clinical, etc) will be incorporated into the matrix

Potential Disease Management KPIs

Payer

Patient

Prescriber

Improved QoL

Better Adherence

Less Hospitalisation

Less Relapse

Reduced Symptoms

Reduced complications

Easier Administration

SimplerTreatment paradigm

Slower Disease

Progression

Fewer Adverse EventsPayer

Patient

Prescriber

Improved value

Societal Burden

PublicHealthPolicy

Drug cost

Driving Patient AccessPathway Inefficiencies: Focusing on Value Opportunity

• Tools can be used in different TAs to capture the interventions and economics associated with current or new SoC

• A simple mechanic is essential as it structures the activities and helps to identify recurring areas of high cost intervention

• Without a tool, there is no structured basis for comparing different treatment paradigm

Capturing Inefficiencies:

Driving Patient AccessPathway Dashboards: Making the Value Opportunity Transparent

• Capturing activity is not enough; it is essential that the key outcomes are presented in a way that is relevant to key stakeholders

• The aim is to help them see the potential impact of changes in the treatment paradigm

• It is the basis of a rationale for committing to new ways of working

• It can include pharmacotherapies as well as other changes to the disease management process

Visible Outcomes:


A partnership is not a nebulous concept with poorly defined stakeholders, for whom success is also not clearly defined.

Equally, changing the SoC will require people to do things differently; to achieve this requires an approach to change management which proactively drives new ways of working and new decision making.

To move to action, commitment is needed from real people who make real decisions based on funding flows and performance vs. outcomes (clinical and economic). Identifying these people and the key influencers is critical to the success of a project of this nature.

Funding Flows and our Key Partners


Map inefficiency

Integrate into

agreement


interventions

What are the key stakeholder’s main priorities?

Key questions in this phase are:• Who are the key stakeholders?• How do they interact with the treatment paradigm in terms of

care provision or funding?• Which decisions are they involved in?• What are their priorities?• Why will they be interested in a partnership?

Driving Patient AccessFunding Flows and our Key Partners


Map inefficiency

Integrate into

agreement


interventions

Outcomes from this phase of the process:

• Payer maps clarifying who is involved

• Clarification of which specific stage each contact is in involved, and what different priorities they may have

• A “change management” summary which proactively identifies what will encourage the required changes to take place


• Moving beyond the patient pathway is a critical step in establishing a partnership; both with the provider, as well as with the patient.

• Understanding the key agents involved in the patient pathway, and the impact of a new therapy on their deliverables and KPIs, is key to understanding the real value of a therapy

• Decision points are often the easiest and most effective points to map, understand and change

Pathway Inefficiencies: Focusing on Value Opportunity

€€€ €€€1o Care Payer

€€€€€€€€2o Care Payer

2o Care Hospital

1o Care Physician

Who has most to gain?

Patient health state


Simple Payer Mapping:Understanding the layers of funding stakeholders.

Funding Archetypes

Cost effective Financial Planning

Stakeholder National Regional Local

Area of interest HTA Regulator Commissioner Insurance Advising Physician

Financial Director

Hospital Pharmacist Clinic

ROI(Insurance/Private) Clinical Value Extended Value Direct Value


Who does a therapy impact?

• Building a template to map disease and care pathways will help to identify the funding archetypes, and whose buy-in could be the most critical to the success of a therapy

Multiple Payer Archetypes

Insurance companies

Driving Patient AccessCan We Create and Show Positive Consequences?

Why will they commit?

• Create a template to map the positive impact of a new paradigm for each stakeholder group:


You cannot know your Payer's priorities; a partnership has to be about what the Payers need as well as what Pharma needs, and so in order to provide a rationale for action we need to establish the following:

• What needs to be done?• Who needs to be involved?• What are the solutions?

And then agreement needs to be reached with Payers:

• What will have most impact?• What is easiest? Quickest? Most cost-effective?• Do you know your Payer's priorities?

Where to Add Value?


Map inefficiency

Integrate into

agreement


interventions

Outcomes from this phase include:• A matrix of Payer preferences and what solutions will be best

suited to achieve listing


If you can show how actions will impact on target KPIs there is a chance that you will be part of the solution

Use pathway to identify stakeholders and their KPIs

• Identify the high impact actions to drive KPIs

Securing Commitment – Understanding Impact

Stakeholder KPI Action Impact KPI Action Impact

Primary care physician Referral levels New SOC M # visits New SoC H

Secondary care physician readmissions New Protocol H # ER visits Support primary

care protocol M

Primary care Payer readmissions New Protocol L Transfer to community Discharge

protocol M

Secondary care Payer LOS 2nd line usage

of therapy H ICU usage 2nd line usage of therapy H


Are your priorities, their priorities?

The pathway will show what each stakeholder experiencesPreferences helps understand what stakeholders want to achieve

The approach is focused on confirming real needs and true wants; mapping actual practice vs. stated policy.

The aim is to confirm which potential actions will resonate and have the highest impact.

Payer Preferences

• What do stakeholders want to achieve?• What do they want to change?

Performance and Outcomes

• Where are the priorities for each stakeholder?• What trade offs are they prepared to accept?Priorities

Driving Patient AccessEstablishing Preferences

Establish a preference model• Sections must reflect Payer, patient and physician relevant needs and outcomes• Use simple tools to capture preferences:

Clinical Preferences• Overall survival• Progression free survival• Controlling/managing common AE• Recued toxicity• Utilities gained, delays

deterioration of QoL & symptoms• Improved control of symptoms • Tumor size• Differentiation to SoC

Process Preferences• Discontinuation• Review of existing drugs• Flow through health care system• Less unplanned events• Efficient use of DRG system• Streamlined decision processes

Policy Preferences • Avoid waste• Disease modifying• Reduction in overall expenditure• Extend life – productivity gains• Personalised medicine• International reference pricing• Equal Access• Use of real world data• Patient registries

Economic Preferences• Adverse event costs• Health Care Resource Use• Extended/indirect costs• Admin costs• Cost-effectiveness• Budget impact – budget certainty• Wastage• Dosing• Over/under prescriptions

Drivers from outside the direct healthcare environment

Drivers relating to Budget Impact (and perhaps Cost Effectiveness)

Drivers based on clinical performance

Drivers relating to the efficient delivery of care and HCP impact

N.B All content is ‘sample’


Integrating Change Into Agreement

Partnerships are not a paper transaction – they are a tangible program of mutually reciprocal actions that change the delivery of health services and associated outcomes.

Important factors for a successful agreement:

• Commitment - this is key to the agreement's success!• Both parties need to commit• The ROI has to be

– transparent for each party– Sufficiently high impact to warrant the associated effort

• Any agreement has to be simple and measurable

Mutual Commitment


Map inefficiency

Integrate into

agreement


interventions

Driving Patient AccessSuccessful Change Requires Commitment to Tangible Actions from Both Parties

Commitment Target Pharma Payer Physicians

Implement new referral process 95%

Payers to communicate to new criteria and

protocol to physicians

Use new SoC in eligible patients 95%

Payers to communicate to new criteria and

protocol to physicians

Provide effective training 95%

Fund protocol development and training for local

physicians

Offer add-on services at first

event95% Funding to be provided Added to protocol

Treat patients in dedicated clinic 95% Change protocol

Reduce indication mortality 95% Rebate? Payers to measure (new

coding required)

Driving Patient AccessTrust is the Driver of Patient Access

The components of the Trust Equation can be managed to help Payers make a positive decision:

• Product Performance – Does the product perform vs. Payer KPIs?• Credibility - If Payers are to buy into an agreement it needs to be clear and simple• Risk - What is the impact to a Payer of the product not delivering on outcomes?

If quality and credibility are very high, and risk is minimised, trust will be higher and the likelihood of a positive Access decision will be considerably increased.

Securing Market Access relies on a Payer trusting that listing and using a therapy will have a tangible positive impact.

Payers do not give a yes, because they do not trust that they will get the promised benefits. Pharma needs to build trust.

Risk=

x CredibilityPerformance Payer Trust

Driving Patient AccessFrom Product to Access

Patient Access starts with a great product that delivers true patient benefit in the form of better outcomes.

But the key to Patient Access is about helping Payers to understand that this benefit will actually be achieved in their Health Economy.

Moreover, given that a Payer must make many listing decisions, it is critical in getting a YES that the product is clearly linked to all important Payer KPIs.

Beyond the patient, Payers have clear disease management objectives and all new therapies need to drive these broader performance goals.

Change requires commitment.

Identifying the inputs from all parties is not about Risk Share or other over-used and misunderstood concepts, it is about mutual commitment to building a revised SoC that will deliver optimum outcomes for all parties – especially the patient.

Driving Patient AccessAuthor

Chris O’NeillCEO and Head of Market Access

Chris O’Neill originally cut his teeth in Sales and Marketing, gaining valuable experience in areas as diverse as food manufacturing, IT and engineering. Always harbouring a rather unhealthy interest in problem solving, Chris decided to take his career experience into the world of Management Consulting; here, he developed valuable new skills that enabled him to understand how to really get ‘under the skin’ of a business.

After almost 10 years of consulting at a senior level, and having a particular interest in Pharma, Chris decided to focus specifically on arguably one of the most important areas of the sector – namely Market Access. .

Understanding how he could use his broader experience to help businesses focus on what really matters, Chris has gained an outstanding reputation for driving positive results and prides himself on his ability to bring a fresh approach to solving sometimes long-standing complex and highly problematic Market Access challenges.

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Curo is a global Market Access consultancy and communications agency. We work with the pharmaceutical industry and healthcare funding bodies (Payers) to enable an innovative and collaborative approach to Market Access for new therapies.

Curo can enable you to formulate a solid Market Access strategy by offering honest perspectives on evidence and value. Working with your HEOR data, our analysts can help you to understand the real-world impact of your therapy in a given disease area. Curo helps you to create a narrative that means much more than just numbers on a spreadsheet – we breathe life into your data.

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Health & Medicine

Patient Access: Getting to YES