When the Patient Loses in Market Access

This issue’s focus topic is Market Access-a very large topic with many nuances. Price and value are now the major determinants of access, and clearly each of those is a multi-pronged discussion unto itself. Our coverage points to an online report in Pharm Exec from the Boston Consulting Group (BCG) Market Access Roundtable, a forum that brings together senior market access leaders and serves as a platform for interactive discussion on

Lisa Henderson

industry-level topics, which tackled the value proposition of therapies in-depth. Outside of European Editor Julian Upton’s report on access in the EU, the other editors focused on employee/employer-related access issues, with topics connected more to how patients pay for their therapies. Those include the trend of under-education among employers on the net effect of their chosen benefit plan designs; the very in-the-weeds subject of co-pay accumulators; and potential disruptors employer coalitions and cash-based pharmacies.

One topic we didn’t focus on is value-based contracts (VBCs), which are often offered as a way for pharma and payers to agree on the terms of payment based on value. However, this year hasn’t seen too much dialogue on the topic. According to PhRMA’s mid-year 2019 report, only one new value-based agreement had been added this year to its ongoing tracking since 2009.

Deloitte noted that barriers to VBCs continue to prevent widespread adoption of these arrangements. In a report published in March, based on stakeholder input from health plans, health systems, pharmaceutical manufacturers, and patient organizations, agreement as to overcoming those barriers would be “for industry players to share the successes and failures of these arrangements more widely.” Another hurdle is the lack of “necessary infrastructure and resources to efficiently collect, link, and analyze the necessary patient data to support VBCs.” Both are not insignificant in time and resources needed to make VBCs a scalable reality.

Physicians say ‘patients first’

Two recently reported events point to the access elephant in the room: how are patients going to pay for their needed drugs and healthcare? These reports focus on physicians going to bat for their patients.

First, from Kaiser Health News, which reported in September that the University of Virginia Health System sued 36,000 patients over six years for more than $100 million, and used aggressive tactics, including seizing wages and savings, which resulted in bankrupting some families. The health system even blocked a UVA undergrad’s enrollment because of an outstanding medical bill, as well as suing 100 of its own employees each year for billing issues. In the intervening months, UVA Health System first said it was well within in rights under the law to collect debt, but now says it will scale back on the reach of its collection activities. However, this may be a little too late as the health system’s own doctors and UVA faculty are speaking out. As stated in the article, “the system’s practices undermined their efforts to improve care for middle- and lower-income families and was not in keeping with an ethos of putting patients first.”

Meanwhile, the patient’s ability to pay came to a head at a recent Heart Failure Society of America meeting, where one of the lead physician authors on a pivotal, Pfizer-funded study of tafamidis publicly decried the drugmaker for the $651-a-day cost of the treatment. In an article published by Bloomberg, Dr. Mathew Maurer said: “[The drug] is equal to a patient’s food budget for a month. Drugs don’t work if people can’t afford to take them…and the pharmaceutical company’s $225,000-a-year price was well out of bounds.”

In the article, Pfizer explains its rationale for the pricing, as well as saying it does offer patient assistance for accessing the drug. However, the Bloomberg piece cites the debate around whether the drug is actually treating a rare disease-Pfizer’s justification for the high cost-or if the true market for the product is much larger than what rare is defined as.

What all of these developments, in different areas, mean for the Market Access function remains to be seen. Clearly, this function will be tackling much more in the coming years.

Lisa Henderson is Editor-in-Chief of Pharm Exec. She can be reached at lhenderson@mmhgroup.com. Follow Lisa on Twitter: @trialsonline