Challenges in Brand Strategies for Tweener Products
The best patient and provider experience will result in a coordination of efforts across the channel continuum.
SPECIALTY MEDICATIONS CONTINUE be at the top of the pack in driving drug costs, accounting for more than one-third of the pharmacy industry’s total prescription dispensing revenue in 2018.1
The definition of a traditional specialty product is well defined across the channel. Common attributes include products that treat serious conditions, are high cost (≥$6K annually), and require comprehensive patient care, drug administration, and reimbursement support. Support services around these products are well established and widely provided.
Manufacturers are faced with optimizing the patient and provider experience regardless of product characteristics by identifying opportunities to improve interventions, mitigate barriers to access, expand open access models, and leverage emerging technology solutions.
What, then, is the solution for the tweener products? These are products for which the price point hovers between $500 to $1000 per month. Although drugs in this category may not need the full complement of high-touch services, they may be candidates for modified programs to support ease of access.
What does often look different is the distribution approach. These products typically fall within a managed model—an open model in which manufacturers contract with select specialty pharmacies to enhance the service offering. Unlike a traditional limited distribution model for which there is a higher level of control, the wider availability of these products results in less control of the end-to-end experience. A major concern that is more pronounced in an open model is the age-old problem of prescription abandonment. Often, the patient suffers from sticker shock when presented with their financial obligation at the point of care and chooses to walk away from therapy.
The rate of prescription abandonment increases steadily as costs exceed $50, with prescription abandonment increasing by 0.6% with every out-ofpocket dollar.2
Therefore, the focus of any channel strategy is to optimize speed-to-therapy and mitigate prescription abandonment, either due to reimbursement hurdles or the patient’s out-of-pocket obligation.
What should the distribution model look like? There are approximately 69,000 pharmacy providers in the US marketplace, from traditional retail to traditional specialty and everything in between.
The candidates in the mix may be emerging national or regional specialty pharmacies and community specialty pharmacies. These pharmacies can provide a strategic advantage given their network of locations and strong relationships with local health care providers.
Not to be forgotten is the retail class of trade, which is formidable and plays a large role to ensure ease of access to these products. Many organizations have specialty products at retail solutions that can be leveraged. Should a claim for any of these products require prior authorization (PA), that claim can be identified, and the reimbursement work shifted to the specialty division for processing. This facilitates access to therapy while not impeding the path of a willing prescription that will flow through the system unobstructed.3
Also percolating in the market are the disruptor models that are finding their way into the pharmacy channel. It is worth keeping an eye on these models as they emerge.
Regardless of the composition of a distribution network, it is imperative that selected partners meet data-reporting requirements, execute patient support programs, and have the technology to deliver the desired patient and provider experience. There is wide variation in the sophistication level of potential channel partners that must be considered when building the optimal channel strategy.
To Hub or Not to Hub
Although traditional specialty products often require full hub services, a modified approach is more appropriate for specialty light products. Balancing the necessary support programs with the financial realities of tweener products is a fine line for manufacturers. A hub-light model providing some services, such as PA and co-pay programs without full high-touch services, is better suited for these products.
Currently, there are many options for a hub-light model in which support services are triggered when there is a need for intervention. Specialty at retail is widely available where PAs are flagged and the heavy lifting of reimbursement is shifted to the specialty arm. The patient can then choose to have the prescription shipped to their location of choice or pick up at the local pharmacy. The key for the success of these programs is to let the prescription flow naturally in the marketplace and intervene only when necessary.
When contemplating the hub model, it is critical to define who is doing what to avoid duplicative efforts, improve efficiencies, and mitigate stakeholder confusion or fatigue. The best patient and provider experience will result in a coordination of efforts across the channel continuum.
Technology Is King
The advancement of innovations in technology such as electronic PAs (ePAs), electronic benefit verifications, electronic health records (EHRs), and prescriber portals provide a valuable ecosystem to expedite speed to therapy.
The ability to conduct real-time benefit checks along with initiating eP As can shave off valuable time. An ePA solution helps improve the efficiency of the process by removing the phone and paper-based manual efforts.
Feedback from providers regarding the administrative burden of complete PAs is real. In many instances, the providers prescribing the tweener products are not accustomed to processing PAs, making the administrative challenges even more pronounced.
Providers report spending an average of 2 business days per week (14.9 hours) completing PA requests.3 There has been widespread adoption of ePAs across the health care network. Nearly 100% of pharmacies, payers, and EHRs have adopted an ePA solution.4
The importance of ePAs has not gone unnoticed by the Centers for Medicare & Medicaid Services (CMS). There is currently a proposal for a new rule that will leverage the National Council for Prescription Drug Programs’ SCRIPT standard for the use of ePA transactions for Medicare Part D claims. Prescribers will be able to determine whether the beneficiary’s plan requires a PA and then submit an eP A in real time, facilitating speed to therapy.5
Despite the advancement of technology, a large volume of PAs are still submitted through phone and fax. The use of ePA is an important cog in the reimbursement wheel. There is clearly more work to be done on this front.
The evolution of high-deductible plans and coinsurance financial responsibilities for patients reinforces the need for a thoughtful approach to the development of co-pay programs. These programs are an important tool in a drug manufacturer’s arsenal to mitigate financial barriers to access.
Overall out-of-pocket costs have risen from $56 billion in 2014 to $61 billion in 2018. As out-of-pocket costs have risen, $13 billion has been of fset by coupons for commercially insured patients.6
Abandonment Rates for Branded Medicines in Commercial Plans
The execution of co-pay programs is particularly significant for products with a lower price point given that they often find their way into the retail class of trade. When developing these programs, the product sponsor must identify which savings offer the best support to brand objectives.7
The identification of unambiguous business rules and safeguards to ensure compliance with federal and state guidelines is a top priority. Other considerations include channel participant technology capabilities, metrics capture, and return on investment measurement. Co-pay accumulator programs are part of a growing trend and have the potential to affect the patient’s out-ofpocket exposure. According to Zitter Health Insights, close to 60% of commercial lives are covered by payers that have implemented a co-pay accumulator program.8
There are a host of solution providers in the marketplace that offer a variety of co-pay programs. The key to success is to ensure that the end result delivers a seamless execution of the patient co-pay program regardless of the point of sale.
In conclusion, a brand strategy for the tweener products requires thoughtful planning to address channel dynamics. The optimal plan must deliver a costeffective model that addresses barriers to access while clearing the path for a willing prescription, optimizing rapid access to therapy and clinical outcomes.
The views expressed in this article are the opinions of the author and not of Optinose Inc.
MARYANN DOWD, RPH, is director of market access operations at Optinose US Inc. Dowd has more than 30 years of experience in the health care sector spanning retail and specialty pharmacy, biotechnology, and management consulting.
- Fein, A. The 2019 Economic Report On US Pharmacies And Pharmacy Benefit Managers. Drugchannelsinstitute.com. Available at drugchannelsinstitute.com/files/2019-PharmacyPBM-DCI-Overview.pdf. Published March 2019. Accessed April 7, 2020.
- Cover My Meds. Available at covermymeds.com/main/medication-access-report/prescription-decision-support. Accessed April 12, 2020.
- 2018 AMA Prior Authorization (PA) Physician Survey. American Medical Association. Available at ama-assn.org/system/files/2019-02/prior-auth-2018.pdf. Accessed April 13, 2020.
- Cover My Meds. Available at covermymeds.com/main/medication-access-report/electronic-prior-authorization/. Accessed April 12, 2020.
- Federal Register. 2020. Medicare Program; Secure Electronic Prior Authorization For Medicare Part D. Available at federalregister.gov/documents/2019/06/19/2019-13028/medicare-program-secure-electronic-prior-authorization-for-medicare-part-d. Accessed April 14, 2020.
- IQVIA Institute. Medicine Use And Spending In The US. Available at iqvia.com/en/insights/the-iqvia-institute/reports/medicine-use-and-spending-in-the-us-a-review-of-2018-and-outlook-to-2023. Accessed April 10, 2020.
- Long, D, Medimpact 2018 Meeting. Conference.medimpact.com. Available at conference.medimpact.com/documents/398252/398821/DougLong_KeynotePresentation_MedImpactAnnualConference2018.pdf/7df9d8b3-8eb5-4bcd-81e7-c1de79a0378e. Accessed April, 13 2020.
- Zitter Health Insights. The Managed Care Biologics & Injectables Index And Oncology Index: Copay Accumulator Programs. Available at drugchannelsinstitute.com/files/Zitter_Copay%20Accumulator%20and%20Maximizer_09.17.2018.pdf. Accessed April, 11 2020.