Pricing and Reimbursement in Respiratory: Payer Views [2020]

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Publication Date:
October 2020
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How have payers met the challenge of COVID-19 and how do they see the future?

The impact of the COVID-19 pandemic has been especially felt in respiratory disease and presents a unique set of challenges for payers. From infrastructure and supply chain issues to budget impact and the expected pricing of vaccines, payers are responding to the current situation while trying to make sense of long-term impacts. What are the issues payers have that pharma needs to be aware of?

To examine approaches to pricing and reimbursement (P&R) in asthma, COPD, lung cancer and rare respiratory diseases, we interviewed US and European payers. In Pricing and Reimbursement in Respiratory: Payer Views they reveal their current concerns, examine how COVID-19 may impact future demand and reveal the strategies they employ for ensuring patient access while controlling drug prices in the face of growing demand.

US and European payers explore key questions:

  • How prepared were payers for the additional demands of the pandemic on their drugs budgets and to what extent has the pandemic revealed weaknesses in prescription drug supply chains?
  • Do payers think the current pricing of remdesivir is acceptable and affordable, and will it be made available to all patients who could benefit from it, or will its price limit patient access?
  • Have there been any issues with rising prices and/or access to supplies of inhaled asthma therapies during the COVID-19 pandemic?
  • Do payers consider triple combination COPD therapies such as GSK's Trelegy and Chiesi's Trimbow represent good value for money in terms of the benefits to patients?
  • Do payers think that the prices of PD-1 inhibitors are representative of the benefits gained for patients with NSCLC?
  • What are the main P&R issues that payers face with regard to drugs for the treatment of rare respiratory diseases?

What industry experts say

"The biologics have come in at a really high price point so those have to be managed, but luckily other standard-of-care items for asthma are pretty low in price. The leukotriene agonists, as an example, in that class you have Singulair, and that's generic. That's less than $20, so that's positive for the budget. We were struggling with albuterol going to HFA and having high costs for the albuterol inhalers, but now, so many of those are available as generics and branded generics, that's a low price point to help offset. And then the other standard-of-care is really inhaled corticosteroids. Those are ranging from $60 to $200. When you look at the preferred tier, the higher cost products seem to bring a once-daily dosing versus twice a day, or it's a long standing, reputable brand. It's not really until you get into things like Dupixent, that's probably around $36,000 per year, that you get concerned even though it is for a niche population of patients that have the Type 2 inflammation, the allergic asthma, and even eczema with allergies. What is becoming the bigger concern is what we're hearing about dual and triple biologic therapy, taking patients that are on Xolair and adding Dupixent as an example."
US Payer 1

"You have to remember that remdesivir's use right now is really mostly inpatient. There's a protocol in place for when it gets used. It has to be within a certain timeline of having developed symptoms or the infection. The payer is not necessarily paying because it's under a DRG [diagnosis-related group]. At the hospital, even at $1,000 [drug cost], if you can shorten the length, or a couple of days of ICU time or ventilator time, although [remdesivir] is expensive, [it still represents a cost saving because] a day in the ICU is $2,500, $3,000. I think everyone would be happier with a lower price point; but given that there's no other alternative and we have it under a protocol, it is being used. But it's really being used inpatient which means the payer's not paying for it."
US Payer 2

"I have heard rumblings and been in some conversations around the idea of the Netflix model where you're paying a fee for a population and then the population is essentially served by the manufacturer. No matter if you have one patient or a hundred patients, it's the population that is being taken care of. I think that is something that is a real possibility and I think that's already happening in certain areas. I think that's probably the innovative reimbursement model that we've discussed the most. Outcomes-based reimbursement has been less moved forward, lower than I expected and it's the difficulties of the data collection that is still the hindrance. I'd like to see value-based insurance or value-based contracting and outcomes reimbursement be the future, and I believe it will be. But the data piece will still be the largest hurdle and until we can get that piece of the square, it's never really going to fully take off. "
US Payer 5

What to expect

A detailed report exploring payer views and attitudes to pricing and reimbursement of therapies for asthma, COPD, lung cancer and rare respiratory diseases:

  • An examination of nine key issues that are impacting P&R decisions for respiratory drugs
  • 24 targeted questions put to US and European payers
  • Their responses which provided 46 insights supported by 73 directly quoted comments

Deliverables: Include a PDF report and a PowerPoint slide deck

Pricing and Reimbursement in Respiratory: Payer Views is delivered as:

  • A detailed PDF report including all insights, quotes and intelligence exhibits
  • A useful PowerPoint slide deck providing a summary of the report's key findings for presentations and sharing with colleagues

Payer contributors

Payers contributing to this report have been screened to ensure they:

  • Have at least three years of experience as a drug-budget manager, P&R expert or health economics expert
  • Have an awareness of the current and evolving issues in the P&R of respiratory drugs
  • Are directly responsible for P&R negotiations for respiratory drugs, whether for a government body, hospital, pharmacy-benefit manager, insurance company, purchasing group or other payer
  • Are a primary decision maker, key influencer or voting/contributing member on a P&R committee, or a drug and therapeutics committee, with direct involvement in reimbursement policy for respiratory drugs

Payers interviewed included:

  • David Levy has worked for the National Health Service for some 20 years and is currently the Regional Medical Director for the Midlands and the East. His previous roles include the Medical Director of United Lincolnshire Hospitals Trust, the President of the British Columbia Cancer Agency, an academic healthcare organisation and posts with the Department of Health, York and Humber SHA and Sheffield Teaching Hospitals, the latter as a consultant neuro-oncologist, managing complex patients and their families.
  • US Payer 1 is a Vice President of Clinical Strategy and Pharmacy and has held various executive leadership roles in specialty pharmacy. Experience includes oversight for pricing, industry and trade relations, client service and service innovation, as well as additions of new services and performance measures.
  • US Payer 2 is a Medical Director who chairs a medical policy committee that provides the criteria for high-cost drugs, medical devices, laboratory procedures and imaging, as well as being part of both a drug review committee and a strategy committee that has input from thought leaders. Discussions cover topics such as new drugs in the pipeline, clinical trial results, drugs that have recently been launched on the market and how the treatment landscape is changing.
  • US Payer 3 is a Pharmacy Director for a regional payer that covers commercial and Medicare lives. He runs a Pharmacy and Therapeutics (P&T) committee and is directly involved in formulary and coverage decisions for drug products.
  • US Payer 4 is a Pharmacy Director for a regional payer that covers commercial and Medicare/Medicaid.
  • US Payer 5 is involved in the overall development of management strategy, including formulary coverage, as well as utilisation management and different trend management opportunities. Prior to that he was involved more on the client side, managing clients in terms of commercial exchange, Medicaid and Medicare programmes.
  • German Payer 1 is Head of Drug Reimbursement for a public healthcare corporation.
  • German Payer 2 has been a member of a board of directors in Baden-Württemberg, with responsibilities for drugs, medical products and therapeutic appliances.
  • Spanish Payer is a Hospital Pharmacy Assistant Director in a large university hospital in Spain.

To ensure full and frank opinions were expressed we have agreed to keep the names of some contributors anonymous.

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