2012 Rheumatology Reimbursement Report
Reimbursement Intelligence, March 2012, Pages: 25
Following the American College of Rheumatology conference in Chicago in November 2011, Reimbursement Intelligence surveyed 50 pharmacy and medical directors representing leading national and regional health plans, as well as 100 rheumatologists involved in patient care.
The report provides precise data, stakeholder insights, and dependable forecasts on what's in store for the RA sector in the near-term future.
The RA stakeholders surveyed for this report will shape the rheumatology landscape in 2012 and beyond. Their opinions are certain to influence the critical choices that lie ahead in RA management.
You can take advantage of their expertise to support your own decision-making about development, positioning, pricing, and marketing in a disease state that is a key driver in specialty pharmacy drug spending.
Survey Results Identify Key Trends Related to Oral Meds, RA Management, Cost of Therapy, and More
Highlights
- Price will likely impact the adoption of new “small molecule” orals, such as Fostamatinib (Pfizer) and Tofacitinib (Rigel)
- Payers are uncertain about the therapeutic positioning for newer small molecule drugs at price parity to biologics
- Provider experience and satisfaction with older agents remains the underlying driver for choice of biologics
- Payers and providers alike do not anticipate a change in the way their plans manage biologics over the next 2 to 4 years
- Despite added bureaucratic complexity from payer restrictions and cost-management strategies, providers generally are successful in overcoming payer obstacles
- An indication for early RA will not likely change current RA biologic prescribing patterns
These are just some of the key findings included in the results of the 2012 Rheumatology Reimbursement Report.
Executive Summary
Key Findings and Strategic Implications
1. Current management trends present strategic opportunities for companies
2. Most companies should not invest in an “early RA” indication
3. Price is likely to be a major factor in positioning of oral small molecules
4. Newer entrants can best differentiate themselves as preferred second-line therapy
5. Positive head-to-head studies demonstrating superiority could compel preferred use
6. Manufacturers need to create programs that offset treatment costs for both patients and payers
Survey Scope and Methodology
Respondent Profile and Demographics
Payers
Figure 1. Number of lives covered by participating payers
Figure 2. More than two-thirds of payers represented commercial plans with three- or four-tier formularies
Rheumatologists
Figure 3. Most rheumatologists surveyed practiced in group settings
Provider investment in reimbursement-related resources
Current Management of Biologic Therapies for RA: Balancing Access and Cost
Figure 4. Payers perceive modest success in managing RA costs, primarily through contracting
Figure 5. Most payers and rheumatologists reported a “regimented” or “somewhat regimented” approach
to managing access to RA medications
Prevalence of Payer Cost-Management Tactics in RA
Figure 6. Payers report a variety of approaches to managing RA costs
Coverage of Biologics under Pharmacy vs. Medical Benefits
Figure 7. Payer coverage of subcutaneous and intravenous biologics under the pharmacy vs. medical benefit
Use of Prior Authorization
Figure 8. The majority of plans require PA for RA biologics
Figure 9. Rheumatologists and payers reported high approval rates for PA
Preferred Products, Tier Placement and Cost-Shifting to Patients
Figure 10. Enbrel and Humira were the preferred biologics for most plans
Figure 11. Nearly three-fourths of payers require coinsurance contributions for Tier 4 specialty
pharmaceuticals
Payer-Perceived Effectiveness of RA Cost-Management Tactics
Rheumatologists' Role in Negotiating Biologic Access
Rheumatologists and Payers Support Early Initiation of Biologic Therapy
2012 Rheumatology Reimbursement eimbursement Report Return to Table of Contents
Biologic Sequencing and Switching
Figure 12. Rheumatologists and payers reported that Enbrel is the most commonly prescribed first biologic
and Humira the most common second biologic
Figure 13. Rheumatologists' line of therapy choices and switching sequence
Figure 14. After 2 anti-TNFs, rheumatologists – but not payers – report switching classes of therapy
Respondent Awareness and Perceptions of Emerging RA Therapies
Figure 15. Rheumatologists reported high awareness of pipeline treatments for RA
Oral Small Molecules for RA
Figure 16. Rheumatologists were somewhat more favorable than payers in their impressions of oral small
molecules for RA
Figure 17. Customers expect oral small molecules will have restricted access similar to biologics
Respondents Disagree About Oral Small Molecule Positioning
Figure 18. Rheumatologists and payers disagree about potential use of oral small molecules
Oral Small Molecules: Price Sensitivity Analysis
Figure 19. At price parity to current biologics, there is no clear positioning for oral small molecules
Figure 20. At a price discount, oral small molecules will be positioned before TNF inhibitors
Figure 21. At a premium price, oral small molecules will be positioned after TNF inhibitors
Perceived Value of Comparative Effectiveness Research (CER)
Figure 22. Demonstration of head-to-head superiority could have an impact on biologic selection
Compliance and Persistence with RA Therapies: The Impact of Patient Cost Burden
Figure 23. High patient cost share was perceived as the greatest potential barrier to biologic use
Figure 24. “Feeling better” and cost constraints were the main reasons for lack of compliance with RA biologics
Rheumatologist and Payer Views of Manufacturer-Sponsored Cost-Offsetting Programs and Initiatives
Figure 25. Rheumatologists value patient assistance programs that make therapy for affordable to patients
Figure 26. Rheumatologists and payers disagree about the value of co-pay programs
Figure 27. Payers believe co-pay programs may influence use of non-preferred products, and increase cost of care to plans
Reimbursement Intelligence: Oral Small Molecules for RA Face High Price-Sensitivity Hurdles
Reimbursement Intelligence, the New Jersey-based market research firm helping biopharma, medical device and diagnostics firms succeed in managed markets, announced the launch of the 2012 Rheumatology Insight Service, a subscription-based market research based on parallel surveys of 100 rheumatologists and 50 payers, which will be continuously updated throughout 2012.
The study, quoted in this morning's Pharmalot, "Yielded some important customer insights," said Rhonda Greenapple, CEO of RI. "One key finding is that the new, oral small molecules for RA are not necessarily a slam-dunk for either payers or rheumatologists."
Greenapple continued, "There was no clear, natural positioning for these agents in RA therapy. Payers and rheumatologists considered them part of the same 'class' as RA biologics, and that where they would be used was highly dependent on cost. Their views varied substantially based on different pricing scenarios."
"We think the message for manufacturers is clear," said Greenapple. "If the manufacturers of novel agents for RA -- including the oral small molecules -- don't clearly position these products in customers' minds, customers, especially payers, will do it for them."
Adoption of these agents will be further challenged by the trend toward shifting of specialty pharmaceuticals to a Tier 4 with higher out-of-pocket costs. Said Greenapple, "Some rheumatologists told us they thought patients will start asking about the new oral small molecules as soon as they're available. The big question is whether they're going to be willing to pay several hundred dollars per month for these medications. Manufacturers have to focus on messaging for three different customer segments -- rheumatologists, payers, and patients. It will take a compelling patient value proposition to motivate patients to start and stay on these new medications."
About the Rheumatology Insight Service
The Rheumatology Insight Service is the first of a new series of category-specific Reimbursement Insight subscription services available only from Reimbursement Intelligence. The core component of the Rheumatology Insight Service is the 2012 Rheumatology Reimbursement Report, featuring more than 50 pages of carefully crafted findings, with thought-provoking commentary from RI's panel of RA category experts. Subscribers to the survey will receive three quarterly updates, periodic event-driven updates, and access to customized sub-analyses of specific customers segments, based on subscriber-requested criteria.
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