Specialty Drugs: An Evolving Commercial Model

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Robin Robinson

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A changing marketplace creates new challenges and new business models for specialty medications.

At the same time the industry is increasing its focus on developing specialty drugs — a projected 40% growth by 2014 and 67% by 2015, according to Express Scripts — the reimbursement, marketing, and sales landscape of these products is also increasing in complexity.

Specialty drugs are defined as being typically high-cost, scientifically engineered drugs used to treat complex, chronic conditions that require special storage, handling, and administration, and involve a significant degree of patient education, monitoring, and management.

According to an Express Scripts report, the number of cancer drugs, considered to be speciality medicines, expected to reach the market alone is predicted to increase by 77.4% over the next three years. Spending on hepatitis C medications will grow by an incredible 465.8% by 2015. Overall, specialty drug spending is expected to more than quadruple by 2020, accounting for about $402 billion a year in sales, CVS Caremark predicts.

However, those large dollars will be hard earned, as many challenges lie ahead for the specialty drug market, including changes in the reimbursement process due to healthcare reform, financial and regulatory pressures, and the need to expand communication to all stakeholders. Addressing these hurdles will generate an evolving commercial model with little resemblance to age-old tactics.

According to Doug Moeller, M.D., medical director, McKesson Health Solutions, one of the industry’s biggest challenges today is letting go of the idea that every drug developed must be a blockbuster.

“One of the ironies of ‘precision’ medicine is that the success of this personalized strategy is breaking patient cohorts into much smaller and more defined groups, and ‘blockbuster’ status may no longer be achievable,” Dr. Moeller says.

“Today’s prevailing efforts in biotech’s battles with viral diseases — many of which fall in the specialty market ­category — focus on therapies for ­cancers, hepatitis C, and HIV— all chronic, potentially fatal, and an unmet therapeutic need,” says Bruce Robinson, a former agency medical director.

Another significant hurdle in the new model is establishing differentiation, says Amber Gilbert, executive VP, director of client services, Ogilvy CommonHealth Payer Marketing, especially since both clinical and economic value will be considered relative to competitors.

“If clinically meaningful differentiation is not established, then it comes down to economic value from the payer’s perspective, which will be manufacturers’ biggest hurdle,” Ms. Gilbert says. “Payers will not hesitate to favor the lower-cost agent if there are no peer-reviewed/evidenced-based data justifying a higher-cost, clinically comparable agent.”

Consumers will stretch the boundaries of comparable, she says.

“On the consumer side, it is entirely possible that patients will be making subjective decisions about value in the specialty pharmacy space,” Ms. Gilbert says. “While payers are likely to direct use toward generics and biosimilars, patients are going to seek out products with the lowest out-of-pocket cost without compromising efficacy.”

Many companies will be exploring the specialty drug market while also maintaining a presence in traditional medicine, a conundrum that may require two sets of management teams.

Mason Tenaglia, VP, managed markets services group, IMS Health, adds that companies with one foot in each sector will need to simultaneously learn how to manage a primary care product along side a specialty one.

“When being ‘big’ becomes less critical, the industry will need to learn how to be big as well as small and flexible, which is a really difficult task for pharma management,” he says. “Everyone is struggling with building the new capability of the specialty drug market while trying to keep the larger drugs moving as well.”

Mr. Tenaglia says the common strategy today is to keep the two pipelines separate, but underneath maintain the same management structure.

“This is the current model that companies are defaulting to and nobody knows really if this is going to work,” he says.

Mr. Tenaglia adds that specialty companies that have been acquired — such as MedImmune and Genzyme — by larger companies are examples of a new transitional model.

The Reimbursement Landscape
According to Express Scripts, 73% of total specialty sales are to independent physician-owned clinics that use the traditional buy-and-bill business model. This model can create challenges for physicians, as they buy the very expensive drugs up front but don’t get reimbursed until after they have been administered — and the risk in today’s reimbursement market is that they may not get paid at all.

This is a problem unique to the specialty market, says Ganesh Vedarajan, managing principal, ZS Associates.

“The challenge is that there is an increased risk to being denied reimbursement, and physicians need to have a strategy in place to deal with this,” he says. “Doctors need to have education and information about prior authorization and they need assistance with knowing how to improve their chances for reimbursement.”

In March 2013, budget sequestration legislated a decline in Medicare reimbursement for specialty drugs by 2%. This added further strain to oncology practices, especially community oncology practices, and is already leading many of them to change their business and clinical practices.

“The industry will need to develop new ways to improve their engagement with oncologists dealing with these reimbursement issues,” Mr. Vedarajan says. “The challenges will be in discovering what any given doctor needs.”

There are a variety of tactics that manufacturers are beginning to employ to help providers in the new marketplace.

“One element is helping physician offices by assisting doctors and practice managers to understand and follow through with the prior authorization process,” Mr. Vedarajan says. “Some manufacturers are also contracting with providers to increase the reimbursement that they receive from administering the drug.”

Payers will also be making new demands of the industry; manufacturers will need to prove the clinical value as well as the economic value of the therapy to payers, physicians, and patients.

The most fundamental premise remains that the therapy provides clinical value, but the bar has been raised beyond just a few more months of survival. For example, in cancer therapy, the endpoint is moving from progression free survival to an increased overall survival rate of the patient.

“The bottom line continues to be pushed in terms of proving clinical value of the drug,” Mr. Vedarajan says.

The Marketing Landscape
In addition to reimbursement issues, companies will have to learn to expand their market research and communications to include all of the channel stakeholders in the new process, not just the payers on the public and commercial side as in the past.

“Today there is more impact by segmentation,” says Randy Vogenberg, Ph.D., principal at Institute for Integrated Healthcare. “Market segmentation is different today than it was before healthcare reform and each segment requires a different value proposition.”

This is a big change for manufacturers to embrace — they need to be aware of who is advising on or will be paying for the treatment, and what their perspective is on identifying value. Dr. Vogenberg says most companies have not begun to do the market research or analysis necessary to be able to identify and properly address each one of these new segments that impact coverage decisions.

“The industry has never had to address the landmines that are associated with what each individual stakeholder thinks the value prop is,” he says. “It’s always been straightforward. They may have worried about distribution channels, but now the whole marketplace is looking at making decisions from a different point of view.”

Healthcare reform has completely changed the marketplace from a predominantly clinical perspective to include financial or economic impact perspectives.

“This has become a big challenge for pharma companies because in the past their whole message has been clinical, and the whole voluntary pharma code was about putting clinical data before economics, but the market now is about economics first, and clinical second,” Dr. Vogenberg says.

A good example of this shift is represented by the new Gilead drug Sovaldi for hepatitis C treatment. According to Forbes, one pill will sell for $1,000, and the treatment is taken once a day for 12 weeks for a total cost of $84,000.

Mr. Robinson says of the viral sciences’ leaps and bounds prayed for by patients and caregivers, hepatitis C therapies of late seem to really deliver. (For more information related to the hepatitis C market, please see the digital edition: Hepatitis C Round-Up.)

“Sovaldi appears to be extremely effective in eradicating the disease, but the cost may be a stumbling block for patients,” Mr. Tenaglia says. “The cost of the drug is going to raise a lot of challenges for employers and insurers, and if they do pay for it, they are going to want to make sure patients take it effectively.”

The Sales Landscape
The industry needs to prepare for the challenges ahead by making changes to its current commercial model. Ms. Gilbert says the biggest change needed in commercial strategies is to purposefully address more audiences with a clear cost-benefit value proposition. Payers are continuing to shift costs to patients at a rapid rate through higher deductibles and a broader use of percent-based co-insurances.

This means that patients will have to bear a significant portion of out-of-pocket costs for specialty drugs. That said, the co-pay card element is likely to be a key piece of any consumer strategy, at least for commercially covered patients, in the near term. If the product is not differentiated clinically, then a dynamic contract offering that delivers added value to payers will be even more critical. One example could be up-front discounts rather than rebates or performance-based contracts.

“We’ll continue to see stakeholders push back on manufacturers for premium pricing of drugs that they perceive as offering minimal efficacy over competing therapies,” says Michael Zilligan, president, Ogilvy CommonHealth Specialty Marketing. “For example, Express Scripts took an aggressive stance toward pricing the new hepatitis C therapies when it suggested the manufacturer had ‘inadequate justification’ for higher pricing versus less convenient therapies that produce similar efficacy.”

Another change will be the importance of collecting and using data to prove better health outcomes through CRM programs, Mr. Tenaglia says.

“Patient behavior will need to be tracked so the loop can be closed and data can be collected on what companies are spending on keeping patients adherent, and what that means to overall health costs,” he says. “Whether it’s claims data or data from copay card suppliers or data from CRM, the biggest management challenge for the next five to 10 years will be how to integrate all of those data sets and infer the results, because results are what’s going to matter in the future.”

This need will drive the significance of CRM programs more than ever. Companies may seek to create websites that engage specialty drug patients and provide them with financial subsidies, drug information, and even adherence devices.

“Devices such as the Fitbit are going to be incredibly important in the coming years in making the link between adherence and results,” Mr. Tenaglia says.

To keep pace with the transitioning marketplace, drug companies will need to become more strategic in their planning, rather than tactical, says Dr. Vogenberg.

“Traditionally, the industry has planned ahead tactically each year at a time, but with the market resetting itself every year due to the effects of healthcare reform, companies can no longer afford to operate that way,” he says. “If a commercial strategy is not in sync with what healthcare reform is doing in the market, that company is going to be headed out of business.”

Dr. Vogenberg predicts it will be another three to five years before the marketplace becomes more solid and easier to predict. During this transition, companies need to factor in healthcare reform into their strategies, and begin focusing not only on what’s happened in the market but also anticipate what will change.

“Most companies today do not have this type of strategy,” he says. “They are preparing to launch products into a market they haven’t anticipated; I know one company that plans to launch a product sometime next year and before that time the market will have shifted twice before the launch, so the launch strategy will be 50% to 60% incorrect at launch. This situation is totally avoidable.”

The current R&D model focuses on a long- term development plan and getting FDA approval and the drug to market, but in the meantime it must closely monitor the changes being made in healthcare coverage, or else it may produce a drug that will not be reimbursed.

“In today’s environment, by the time the product receives FDA approval, the traditional commercial insurance market might be shut down and become a defined benefit, which means the company won’t be able to sell the product, or at least not at the price they intended,” Dr. Vogenberg says. “It sounds surprising, but many companies do not know the fundamentals about how the healthcare market and insurance work. They don’t have a basic understanding on market fundamentals, such as that there is a finite amount of money and if the drug’s value doesn’t make sense to those who are paying, then it has no value.”

The commercial model for specialty drugs is very different from the model for primary care, and drug companies with new specialty drugs will need to adjust their strategy, Mr. Vedarajan notes.

There are four elements that differ greatly between the two commercial models, he says. As already noted, reimbursement has become much more complex, for one. Identifying the needs of the specialty physician is another difference, he says. Discussions with specialty clinicians are much more detailed than the clinical discussions with primary care physicians. Also, specialty physicians can no longer be lumped together as one group as in the past.

“There was a time when specialists were considered as all the same, but today, every oncologist is different and every practice setting is different,” Mr. Vedarajan says. “While PCP visits are typically 10 to 30 seconds long, specialty appointments are scheduled months in advance and the discussion can last 10 to 30 minutes, during which a lot of clinical data are supplied through multimedia detailing techniques. There is also a lot of support provided to the practice, especially to the nurses who must anticipate side effects of a patient during infusion care and to practice managers to help them bill the hundreds of thousands of dollars of claims correctly. The clinical and sales support to sell the specialty drug is significantly more intense and complex than sales for a primary care drug.”

Distribution strategies are very different as well. PCP patients go into a pharmacy and pick up their drugs, but specialty drugs are either buy and bill through the physician or sold from a specialty pharmacy to the physician or the patient.

And lastly, many specialty drugs need to be tested before they are implemented to determine if the drug is right for each patient, which creates new challenges for physicians and manufacturers. Drug companies will have to create a way to support this testing.

One of the biggest overall changes in strategy, however, is the move from a product-focused model to a solutions model.

There will soon be a time when payers will contract not just on volume but on the outcome along the patient journey.

“This is an important change for practices because they will not be measured on volume of services but on patient outcomes and they will be looking to share this responsibility with the manufacturers, who will in turn need to change the business model to a more outcome or solutions based mindset,” Mr. Vedarajan says.

According to Dr. Moeller, the single most important change will be more transparency and consensus regarding the evidence-based criteria for adding emerging technologies — diagnostic and therapeutic — to accepted clinical care protocols.

“Unfortunately, emerging means just that,” he says. “We don’t quite have enough reliable, objective information to approve this test or therapy as fully approved. Even so, competitive pressure and anti-trust provisions should not prevent a marketplace from establishing thoughtful and useful quality-of-care criteria and measures.”

According to Mr. Zilligan, the industry can prepare for the future and the new commercial model by creating strong relationships with patient advocacy groups and developing a deep understanding of the sociology, psychology, and economics of the disease state as it relates to not just one patient — personalized medicine is becoming more of the norm in oncology, for example — but all typical patient types.

“Companies will need to approach and work with all stakeholders as if they operate in a common ecosystem and master all of the functional variables that impact each key player, for example, a nurse navigator,” he says.

Mr. Zilligan says as the specialty space moves to a more “mature” point in its evolution, payers will demand lower pricing, likely through more aggressive contracting. And incremental value will flow from the use of technologies — digital pill boxes, Web-based solutions, etc. — that can be integrated into adherence strategies.

“For pharma, the benefits will be the ability to command premium pricing for genuine superiority; the risk will be no-holds-barred commoditization and heavy payer restrictions on products deemed as having too high a price for the benefit offered,” he says.

Success will stem from a strong R&D strategy, with input and alignment between medical and commercial teams, as well as strong business-to-business relationships, which will open doors to new sources of real-world data.

Advanced and real-time analytics will become critical to ensure that the clinical and economic value story communications are being resourced and targeted in the correct channels and segments. A strong partnership model will evolve in the contracting environment, Mr. Zilligan predicts.

“One the biggest differences in the next five or 10 years may depend on the timing of biosimiliars in the United States,” he says. “The strategies pharma develops and deploys to address these pending lower cost market entrants will no doubt be critical. Companies need to guard against having market leadership and then confronting either a low-cost or higher-quality competitor and being caught flat-footed when a clear strategic response was called for.”

Fast Fact In 2018, six of the 10 ­ best-selling drugs by revenue are projected to be specialty drugs, compared with three drugs in 2010 and five in 2012. EvaluatePharma World Preview 2013, Outlook to 2018

Fast Fact Specialty drug spending is ­expected to more than quadruple by 2020, reaching about $402 billion a year. Fewer than 4% of patients use specialty medications, but they account for 25% of ­healthcare costs. Source: CVS Caremark

Specialty Pharmaceuticals: A Resource Guide
Informational links to reports on general trends in use and cost, benefit design, and trends related to specialty diseases and drugs.

» 2013 Specialty Trend Management Insights Report from CVSCaremark reports on recent ­specialty pharmacy prescribing trends and ­strategies for managing costs.
For more information, visit cvscaremarkfyi.com/insights-2013.

» Aon Hewitt Health Care Trends Survey ­summarizes forecasted healthcare trend data (medical, dental, pharmacy, vision benefit trends for various plan types) based on information from leading healthcare vendors.
For more information, visit aon.com/ attachments/human-capitalconsulting/2013_Health_Care_Survey.pdf

» EMD Serono Specialty Digest is a report based on compiled survey results and used by ­healthcare decision makers to benchmark their management of specialty pharmaceuticals against their peers. Each digest provides a ­comprehensive overview of managed care ­challenges and opportunities as well as current and future trends in managing specialty ­pharmaceuticals. Survey results come from ­various private and public health plans and ­pharmacy benefit managers.
For more information, visit specialtydigest.emdserono.com/

» Magellan Pharmacy Solutions’ 2012 Medical Pharmacy & Oncology Trend Report provides a source for trends and benchmarking statistics for injectables paid under the medical benefit. By surveying 50 top U.S. commercial health plans, representing almost 160 million lives, the report leverages three years of trend report benchmarking data.
For more information, visit icorehealthcare.com/icore-resources/trend-report.aspx

» Managing MS: Trends, Issues and ­Perspectives. This Biotechnology Healthcare report outlines the impact of the entry of oral medications for multiple sclerosis into the ­marketplace and challenges for all stakeholders from the high cost of biologic drugs.
For more information, visit ncbi.nlm.nih.gov/pmc/articles/PMC3138383

» Multiple Sclerosis Trend Report, 2nd Edition is the National Multiple Sclerosis Society and Teva Neuroscience survey of key stakeholders, ­physicians, MCOs, and specialty pharmacies on their views of the management of MS in the managed care environment.
For more information, visit nationalmssociety.org/research/research-news/ms-trend-report/index.aspx

» Walgreens Specialty Pipeline Report ­provides a summary of the specialty ­medications that may be approved by the FDA within the next few years.
For more information, visit walgreens.com/pdf/newsletterreport/ Pipeline_Report_4Q2013.pdf

Oncology Most Restrictive Specialty For Second Year
Oncology remains the most restrictive specialty for sales representative access this year for the second year in a row. A ZS Associates report found that about 65% of oncologists in the United States placed moderate-to-severe restrictions on visits from sales reps. By comparison, only 17% of oncologists restricted access to reps in 2008. About 58% of cardiologists and 47% of primary care physicians restrict rep access to the same degree.
Oncology is the most restrictive of the 20 common medical specialties noted in the report.
Source: ZS Associates


“A significant hurdle in the new commercial model is ­establishing differentiation. ” Amber Gilbert Ogilvy CommonHealth Payer Marketing “The industry will need to ­develop new ways to improve its engagement with oncologists; the challenge will be discovering what any given doctor needs. ” Ganesh Vedarajan/ZS Associates

“The industry can prepare for the future and the new commercial model by developing a deep understanding of the sociology, psychology, and economics of the disease state as it relates to not just one patient, but all typical patient types. ”
MICHAEL ZILLIGAN/Ogilvy CommonHealth Specialty Marketing

“The cost of specialty drugs is going to raise a lot of challenges for employers and insurers.”

“A significant hurdle in the new commercial model is establishing differentiation.”
AMBER GILBERT/Ogilvy CommonHealth Payer Marketing

“The industry will need to develop new ways to improve its engagement with oncologists; the challenge will be discovering what any given doctor needs. ”

“Market segmentation is different today than it was before healthcare reform, and each segment requires a different value proposition.”
DR. RANDY VOGENBERG/Institute for Integrated Healthcare

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