Insights from PCMA: top market access signals

The Pharmaceutical Care Management Association Business Forum, held annually at the end of February, is an opportunity to get a read on the year’s key drug reimbursement and coverage trends.

Here are the top three signals the Real Endpoints team took away from the event:

1.?Value-based agreements: All the cool kids are doing them – or at least talking about them

Value based agreements – or VBAs, for short – are top of mind for many market access teams these days. But the truth is, models that actually share risk between manufacturers and payers are as rare as winning Wordle on the first try on back-to-back days.

Trust me, we have heard all the reasons not to do VBAs, with the five most common explanations being: 1. payers would prefer a straight rebate; 2. VBAs are too complex to manage; 3. the impact to a drug’s Medicaid best price; 4. the effect on average sales price for medicines that physicians buy and bill; 5. concerns about patient portability, especially for expensive therapies of unknown durability.

The knee-jerk reaction to VBAs is unfortunate, because for the right drugs, especially in the rare or orphan space, they can be a powerful tool to achieve maximum access. And increasingly, there are a range of options that can be constructed to reduce risk and make high-priced curative drugs more attractive to payers, and importantly, more accessible to patients.?

Key takeaway: VBAs remain an under-utilized strategy for many manufacturers. Whether they are implemented as a reaction to marketplace dynamics or positioned proactively with payers as part of a broader access strategy, companies should understand – and prepare – as part of their launch planning for conditions that trigger the need for a VBA.

2. The Humira biosimilars are coming – but will anything change?

You may have heard that come 2023, AbbVie’s?blockbuster TNF inhibitor Humira?will face biosimilar competition from seven?different adalimumab makers. Listening to the big pharmacy benefit managers?at PCMA, their objective is to?ink contracts that allow them to achieve?the lowest net cost for adalimumab.

But?it’s an open question whether Humira, the?top selling drug since 2012, will be deposed. Given Humira’s advantages in market share and COGS, biosimilars face an uphill, but not impossible, battle.

Key takeaway: As the jockeying for formulary position commences, there won’t be a single formula for success. Biosimilar manufacturers will need to consider how they compete with entrenched competitors that also bring decades of entrenched patient services. Indeed, delivering access on terms that providers and patients will accept is paramount: positive coverage decisions won’t mean anything if those stakeholders aren’t interested in using the product.

3. You already knew this, but disrupting healthcare is hard

A presentation by J.P. Morgan’s Lisa Gill reinforced just how hard it is for new health tech disruptors to create lasting change when it comes to drug pricing and access. This subject was also a theme in nearly every conversation we had at PCMA. Sure, there was chatter about PillPack, EQRx and Mark Cuban’s new CostPlus drug model, but it wasn’t necessarily linked to the reasons those companies were founded.

Let’s be clear, though. The difficulties faced by newer entrants to bring transparency and deliver drugs more cheaply doesn’t mean those issues aren’t priorities for a range of stakeholders around the country. Indeed, in the last two weeks, as discussions at the federal level stall out we’ve seen even more signs of aggressive action from states. Look no further than news about the expansion of the Northwest Prescription Drug Consortium or the state of California’s decision to work with ICER to develop annual price hike reports.

Key takeaway: Manufacturers are going to need to spend more time developing narratives about how they price for value – and begin communicating that narrative to a growing array of payer stakeholders.?

Did you attend PCMA? If yes, what else did you hear that is worth sharing with this community? Please chime in with your own analysis – or ask a question to continue the discussion.