Asembia 2023: Payers, Pharma and Pharmacy Discuss Patient Access
Select Wednesday sessions at Asembia 2023 focused on how patients access and afford specialty therapies, including plan design and the patient and care team experience. Presenters with pharma, payer and pharmacy backgrounds shared diverse points of view on patient access.
Presenters with pharma, payer and pharmacy backgrounds shared Wednesday at Asembia 2023 diverse points of view on patient access and affordability for specialty therapies.
The impact of the Inflation Reduction Act, or IRA, was once again a topic of conversation Wednesday, with presenters discussing how Medicare Part D benefit reforms will affect treatment access and affordability assistance for patients with complex conditions.
Presenters also debated to what extent value-based contracting and alternative funding arrangements are catching on and stressed the importance for data connectivity in helping to advance specialty care.
Monday’s recap, “Expectations and Policy Impacts for Specialty Therapies in 2023,” examined the robust specialty therapy pipeline in the coming year and how the industry can prepare for a shifting policy landscape — most notably, the Inflation Reduction Act.
Tuesday’s recap, “An Active and Complex Future for Specialty Therapies,” examined what promises to be an active future in the field of specialty therapies and how the industry should evolve to best serve patients in an increasingly complex environment.
Asembia 2023: Day 3, Session 1
“Post-Inflation Reduction Act: The Continued Need for Charitable Patient Assistance”
Presenters: Kelly Brantley, practice director, Avalere Health; Carmine DeNardo, vice president and general manager, Omnicell Specialty Pharmacy Services; Kevin Hagan, president and CEO, PAN Foundation
Summary: What was discussed
A recurring topic of conversation at this year’s conference was the Inflation Reduction Act, or IRA for short. Passed by Congress in 2022, the IRA includes several provisions aimed at lowering the cost of prescription drugs, most notably allowing Medicare to negotiate with manufacturers on the prices of certain drugs.
In this session, presenters discussed how the IRA’s Medicare Part D benefit reforms will impact access to treatment and the need for financial assistance for patients with complex conditions.
Getting patients on therapy as fast as possible and keeping them on therapy will ultimately help their health outcomes.
Kevin HaganPresident and CEO, PAN Foundation
Key takeaways
Patient populations most likely to need financial assistance from charitable foundations are Black and Hispanic adults, as well as adults with annual incomes less than $50,000.National polling: adults face challenges affording prescriptions, PAN Foundation, 2022
Affordability relief for patients may come from the IRA’s cap on prescription costs, but it will not arrive for a few more years, presenters said. In 2025, there will be a cap of $2,000 per year on out-of-pocket expenses for prescription medications for people covered by Medicare Part D plans.
Also coming in 2025 are provisions of the IRA that set monthly limits on out-of-pocket costs, again for people covered by Medicare Part D plans. Presenters described how this can help “smooth” costs for patients, especially those that face higher expenses at the beginning of the year after deductibles reset, by setting up installments.
“Understanding the unique needs and circumstances of patients is crucial to providing the most effective support and assistance,” said Kelly Brantley, practice director, Avalere Health.
The industry call to action
Preserve Medication Affordability Options
Patients have a great need for medication affordability support, presenters said. According to a recent CoverMyMeds patient survey, 60% discovered a prescription was more expensive than expected in the past year — leading 1 in 4 to abandon their medication.CoverMyMeds Patient Survey, 2022
Additionally, 28% of patients said they’ve sacrificed essential items or bills in the last year to afford their medications and 17% have sacrificed their medications to pay for essential items or bills.CoverMyMeds Patient Survey, 2022
The rest of this year holds similar anticipated affordability challenges for many patients, too. More than half said they expect inflation to impact their ability to afford their medications in 2023 compared to the previous year.CoverMyMeds Patient Survey, 2022 One in 10 said they will not be able to afford their medications at all.
Pave the Path to Medication Adherence
Financial assistance, such as pharma-sponsored copay programs, could reduce the likelihood of patients not picking up their prescription(s) by more than 70%, according to a recent Journal of Managed Care + Specialty Pharmacy study.Copay assistance use and prescription abandonment across race, ethnicity, or household income levels for select rheumatoid arthritis and oral oncolytic medicines, Journal of Managed Care and Specialty Pharmacy, March 2023 More specifically, the study found that copay was “associated” or “correlated” with a 79% decrease in odds of prescription abandonment in Rheumatoid Arthritis medications only.
Pharma decision-makers appear to prefer this path to adherence, too. In a recent survey, pharma leaders reported affordability programs, like patient assistance programs (PAP), have the greatest impact on patient adherence to their medication.CoverMyMeds Pharma Survey, 2022
Presenters said tools that help care teams connect patients to affordability options, like pharma-sponsored copay cards and PAP, can help patients get and stay on their medication. Hagan also reminded the audience to consider the whole patient when exploring their best options.
“As a patient advocate told me, ‘I have a life, I'm more than a pill, because prescriptions are only one piece of the equation for me,’” Hagan said.
Asembia 2023: Day 3, Session 2
“Plan Sponsors Speak: Viewpoints and Trends in Specialty Drug Benefit Design”
Presenters: Morgan Lee, senior director, research and strategy, Pharmaceutical Strategies Group; Michael Medel, senior vice president, consulting, Pharmaceutical Strategies Group; Renee Rayburg, vice president, specialty clinical consulting, Pharmaceutical Strategies Group
Summary: What was discussed
Drawing on the results from a national survey of plan sponsors for the Specialty Drug Benefit Design Report, this session provided insights into the current and planned trends in specialty benefit design and utilization management.
Presenters offered perspectives from stakeholders across the industry, such as payers, employer groups and providers, and discussed to what extent value-based contracting and alternative funding arrangements are catching on. The Pharmaceutical Strategies Group also weighed the importance of specialty drug benefits to patients with plan-sponsor challenges to control costs.
Bottom line: The tug of war will have an impact on patient access, presenters said.
“It’s a complex process,” Rayburg said. “It’s hard on patients.”
(Payers) see the coverage of the high-cost specialty drugs as an investment in the health of their members.
Renee RayburgVice president, specialty clinical consulting, Pharmaceutical Strategies Group
Key takeaways
Balance Affordable Member Costs and Premiums with Coverage Decisions
Plans seek to manage coverage of specialty medications through prescription benefit design. Formulary tiers, cost sharing and utilization management tools help plans balance affordable premiums with risk. Specialty medications represent a large percentage, 50% or more according to the Pharmaceutical Strategies Group, of overall drug spend by plan sponsors.
Justify What Can Be a Costly Specialty Drug Spend with Life-Changing Value to Patients
Despite high costs, Rayburg said there is good reason to invest in these therapies. Proof that a therapy can lead to better health outcomes and lower costs or ROI in the long run will be more attractive to payers.
Get a Grip on the True Expense
Payment method (pharmacy benefit, medical benefit or mix), site of care, route of administration and various drug channels create a complex environment that can cloud the picture of drug utilization and costs.
The industry call to action
Innovate for Sustainable Specialty Medication Coverage
Presenters addressed the need for novel and sustainable benefit designs to smooth the turbulence from a specialty spend that has grown 43% since 2016 to total $301 billion in 2021, according to government data.Trends in Prescription Drug Spending, 2016-2021, Page 7, Assistant Secretary for Planning and Evaluation, Office of Science and Data Policy, September 2022
Asembia 2023: Day 3, Session 3
Session: “Customer and Prescriber Experience Transformation”
Presenters: Olga Korsunsky, executive director, prescriber connectivity and innovation, CVS Health; Christine Sawicki, executive director, CVS specialty patient innovation, CVS Health
Summary: What was discussed
This session dove into the ways data connectivity is helping advance specialty care. Presenters from CVS acknowledged the role pharmacists play in patient care, which has expanded significantly in recent years.
Specialty pharmacists have long played a key role in patient care — including helping people get and stay on therapy. Sawicki and Korsunsky took attendees through the patient journey to highlight how engagement and utilization of healthcare systems, such as EHRs, can help automate aspects of the specialty patient journey.
Connected solutions help make it easier for patients to manager their health.
Christine SawickiExecutive director, CVS specialty patient innovation, CVS Health
Key takeaways
Korsunsky and Sawicki said that a connected environment throughout the patient journey is required to deliver the cohesive, comprehensive and personalized experience patients now expect.
The presenters went on to explain how digitally enabled healthcare experiences that help make healthcare more affordable, accessible and convenient for patients are gaining momentum.
For patients prescribed specialty therapies, it’s important to take the medication as prescribed. Sawicki said patient data and digital tools are needed to intervene with the patient when they are starting on a specialty drug.
“A non-adherent patient might become adherent, and you don’t want to continue to trigger interventions when the behavior has been modified,” Sawicki said.
The industry call to action
Help Care Teams Help Patients
Asembia presenters cautioned that the IRA, specifically drug-price negotiation, is likely to cause disruptions for providers, including health systems, community oncologists and retail pharmacies.
Such disruption could materialize through changing formularies, resulting in an additional burden on care teams to help patients navigate their treatment plan. For example, a patient may have to switch to a therapeutic alternative or obtain approval on a prior authorization request if their insurance coverage changes.
In this scenario, a transformed care environment — like presenters envision — could make it easier for care teams and their patients to access information, such as a patient’s formulary design, necessary to get prescribed medication.
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