Segmentation, Contracting, Gross to Net and Understanding Payers

A Case Study

A small to mid-sized US pharmaceutical manufacturer preparing to launch a new product hired us to maximize their positioning within a competitive market landscape. The project objectives were wide-ranging, consisting of segmenting payers to understand volume and access contribution, prioritizing MCO accounts, and selectively contracting to improve access and utilization management (UM). The client also wanted to attain formulary access based on access value to the brand, the relative opportunity and likelihood of payers to manage product utilization, the relative value of access on a channel/ segment/customer level using claims, and formulary data. Lastly, the client sought to develop a net price strategy through the segmentation exercise to create contract guidelines and assess gross-to-net.

We approached the analysis of third-party* formulary access and utilization data by segmenting payers according to their willingness to manage products and the size of the opportunity, resulting in the creation of contract guidelines. We targeted critical payers in major segments (making up 80%-90% of the segment volume) according to their percent volume and revenue contribution to the overall brand volume. We determined the appropriate performance metrics (market share and rejection rate), matched those metrics to different access/restrictions levels, and assessed performance based on an absolute and relative manner. Payers within segments were prioritized for access impact, looking for natural UM groups, and comparing and contrasting performance for different UM groups both within and across segments. Using the data analytics, we then created contract guidelines for each channel, segment, and subsegment by valuing access and/or UM changes to improvements in market share and rejection rates. We then utilized contract guidelines to develop a five-year gross-to-net model using channel and payer mix for commercial and government payers, including voluntary and mandatory discounts. Ultimately, this allowed the client to focus on high-value payers and to negotiate with them more effectively and profitably.

*3rd party data included MMIT and IQVIA FIA

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