Under the Influence of Payers
By: Ryan Wooller | September 17, 2014
In healthcare, finding the answer to those questions is inextricably linked to understanding value. The stakeholder most able to position themselves as defining value is the one who ultimately shapes which drugs are developed, commercialised and prescribed, and therefore ultimately whether or not patient needs are met. So in the complex local health economies we find ourselves working in, who is it that wields the most influence?
Tipping the balance towards payers
The climate is becoming increasingly complex following the changes to the NHS in 2013. There are now potentially as many different definitions of value as there are budget-holders, and that's before considering the attitudes of providers and biopharma. The UK's healthcare system is now fragmented, with 221 clinical commissioning groups (CCGs) purchasing at a local level. The NHS no longer has a single market access gatekeeper, so biopharma must instead understand each CCG's unique value requirements, then deliver on those priorities if they are to successfully reach patients across the length and breadth of the country, and beyond.
So going forward, does this mean that payers are in control? Are they the ones deciding what value means for their specific patient population, then requiring biopharma to follow their lead? According to a Quintiles stakeholder survey, the answer appears to be yes.
The league table of influence
When we specifically questioned payers and providers, the overwhelming majority believed payers have the most influence on how value will be defined within the next three to five years. Some 66 per cent of providers and 59 per cent of EU payers ranked them in the top two. Regulators also scored highly, with 36 per cent of EU payers saying regulators will be most influential in the coming years.
Figure 1: Percentage of stakeholder who ranked payers in their top two
Aligning with payer priorities
So for the immediate future at least, payers appear to be in the driving seat. A long-term goal for biopharma may be to redress the balance so they are seen as a more dominant player in defining value, but in the short term, they must work out how to align their priorities with those of the payers.
In practice this means accepting that regulatory approval is not enough to demonstrate value to payers, who instead see real-world data as essential to proving measurable improvements in local health outcomes. Similarly, our cost-conscious healthcare system dictates that payers and providers are likely to reject even highly effective treatment options if they are seen as too expensive. Therefore biopharma needs a firm grip on cost-savings throughout the development and delivery cycle, while maintaining the highest standards of innovation, safety and efficacy. Looking at value through the eyes of payers will be vital.
Ultimately, Biopharma needs to reassert the fact that it plays a critical part in the value chain, and convince stakeholders it is uniquely positioned to develop treatments that deliver the value story that customers demand. That means building positive, transparent relationships with payers, and working collaboratively to define value. Then by presenting compelling evidence backed up by reliable real-world data, they will be able to show that their products perfectly encapsulate what the wider healthcare economy is striving to achieve.
But a word of warning: this repositioning is unlikely to be easy. Before biopharma can demonstrate value, they need to address one of the most concerning findings to come out of our survey: lack of trust. Some 54 per cent of EU payers said they were 'not at all' or 'not very confident' in biopharma's claims about value, and over 40 per cent felt equally doubtful about the completeness, transparency and reliability of the information biopharma companies provide to demonstrate value. Is this a reflection of pharma’s creativity in articulating value to respond to payers value requests in this ‘transition’ phase - whilst the old way of constructing clinical trials and demonstrating outcomes catches up with modern healthcare requirements? We cannot be sure.
Clearly then the challenge is two-fold, because there is little use in perfectly aligning your definitions of value if nobody believes you. In such a delicately balanced environment with so many stakeholders vying for influence, trust may well be the key that unlocks the market for biopharma.
Ryan Wooller will be exploring this key issue in more detail as part of the UK Market Access Payer Perspectives Webinar Series, alongside Dr Junaid Bajwa a GP and Board member for Greenwich CCG. To hear first-hand insight from both biopharma and payer stakeholders on this new challenge for UK market access, and the opportunity to take part in what promises to be an enlightening Q and A, book your place for the 24 September webinar here: http://bit.ly/QuintilesPPWebinar