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We were unable to process your request. Please try again later. If you continue to have this issue please contact customerservice@slackinc.com. Back to Healio Key takeaways: More than 60% of executives said specialty pharmacy optimization will have the greatest impact on their business. Nearly half said payer-provider integration will impact coordination of care for patients. Executives from the largest U.S. health care payers cited proactive management of high-risk patients, biosimilar use and site-of-care steerage as their top tactics to lower care costs, according to a survey from Spherix Global Insights. Spherix surveyed 27 decision-makers from nine of the leading managed care organizations and pharmacy benefit managers (PBMs) in the United States: UnitedHealth Group, CVS Health, Cigna, Kaiser Permanente, Elevance Health, Humana, Health Care Service Corporation, Molina Healthcare, and Centene Corporation. The respondents included directors of pharmacy, planning and network strategy, along with vice presidents of pharmacy strategy and chief medical officers.
\u201cThe purpose of this study is to get a deep understanding of the top nine payers in the U.S. market today and highlight how each approaches the market differently,\u201d Sybil Mead, vice president of market access at Spherix Global Insights, told Healio. \u201cThe mixed quantitative and qualitative methodology is best to get us beyond the publicly available financial and other secondary-sourced information, to the nuance of strategy and outlook directly from the decision-makers\u2019 perspectives.\u201d Sybil Mead The survey was meant to detail specific areas of the U.S. health care market, including positioning, growth strategy, partnerships and engagement with biopharmaceutical companies, and future drivers, according to Mead. \u201cThe volume of these top payers is compelling for drug access,\u201d she said. \u201cLarge leading payers, serving the most significant number of insured individuals, set the scene for business priorities and innovations across the industry. These leading nine payers have distinct operating models with different approaches to integration, pharmacy management and growth.\u201d Relationships and partnerships between payers and industry can shape real-world prescribing patterns, sometimes as much or more than clinical guidelines do, according to Aaron Broadwell, MD, assistant professor at the Louisiana State University Health Sciences Center. \u201cIt is critically important for physicians to understand how payers view the health care system, because payers increasingly influence the environment in which we actually deliver care,\u201d he said in an interview. \u201cClinical evidence tells us what treatments can work, but coverage policies, prior authorization, formularies, site-of-care requirements, network design and reimbursement policies often determine whether and how a patient actually receives that treatment.\u201d The survey results can offer important insight into the incentives driving those decisions, he added. \u201cPayer executives are clearly thinking about total cost of care, specialty drug spending, vertical integration, analytics and automation,\u201d Broadwell said, advising that the clinical community should not be left out of these conversations. \u201cA policy that looks efficient on a spreadsheet frequently has unintended consequences at the patient level,\u201d he said. \u201cThe best outcomes are going to come when payer data and economic expertise are combined with the experience of clinicians who understand what happens to actual patients when access is delayed, treatment is changed, or care is fragmented.\u201d A close examination of the survey responses, including the opinions expressed on integration of care between payers and providers, could shed light on whether those outcomes can be achieved. \u2018Changing the basic infrastructure\u2019 As part of the survey, respondents were asked about the impacts of integration of care between payers and providers. Results showed that 48% of respondents said it would impact coordination of care for patients, while 44% each reported that it would impact the ability to influence site-of-care decisions for specialty medications and the integration of health care services across care. Further data showed that 41% of respondents suggested that integration would impact negotiated provider reimbursement rates and medical pricing dynamics. \u201cThe greatest effects of integration are not necessarily traditional formulary decisions,\u201d Broadwell said. \u201cThey are coordination of care, site-of-care decisions, integration of services, and provider reimbursement and pricing. \u201cThat tells me vertical integration is changing the basic infrastructure through which care is delivered,\u201d he added. Integration creates potential conflicts that payers need to acknowledge, according to Broadwell. \u201cWhen the same corporate entity has influence over the health plan, the PBM, the specialty pharmacy and portions of the provider network, a decision about where a patient receives a medication or which channel supplies it may have both clinical and financial implications,\u201d he said. \u201cWe have to be careful not to assume that moving a patient to an affiliated site or pharmacy is automatically synonymous with better coordination or lower total cost, but we can be sure it is what is the most profitable for the insurer.\u201d These are not the best metrics to assess the effectiveness of a health care strategy, according to Broadwell. \u201cThe appropriate measure of successful integration is not how much care is captured within an organization\u2019s own ecosystem,\u201d he said. \u201cThe measure should be whether patients have better outcomes, more timely access, less fragmentation and a lower true total cost of care, not more profit for the insurance plan.\u201d The data may speak less about patient care than they do about control of the system, according to Mead. \u201cIn general, payers have embraced vertical integration to expand control across the care continuum, with increased investment in provider assets, specialty pharmacy and data capabilities,\u201d she said. \u201cThese moves are enabling tighter coordination between medical and pharmacy benefits, and more influence over access and utilization decisions.\u201d This can have implications at the systemic and individual level, according to Mead. \u201cWhen providers are owned by or affiliated with the payer, clinical decisions will be tightly aligned with financial decisions,\u201d she said. \u201cOwned physicians are much more likely to be compliant with formularies and pathways than non-owned providers.\u201d<\/p>\n","protected":false},"author":1,"featured_media":3203,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[],"class_list":["post-3202","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-uncategorized"],"_links":{"self":[{"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=\/wp\/v2\/posts\/3202","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=3202"}],"version-history":[{"count":0,"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=\/wp\/v2\/posts\/3202\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=\/wp\/v2\/media\/3203"}],"wp:attachment":[{"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=3202"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=3202"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=3202"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}
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