Why Market Access is Crucial for Healthcare Marketers Today

When MedSpan was founded in 1996, addressing issues surrounding market access was not a high priority objective.  Healthcare product marketers figured that if they convinced physicians of the value of their drug, device, assay or imaging procedure, reimbursement would take care of itself.  For products purchased by hospitals, or intermediate or long-term care facilities, healthcare marketers figured that the institutions would give physicians whatever they wanted.

However, times have changed.  The rising cost of delivering healthcare and the increasing availability of comparable products encourages payers to more closely manage access.  Therefore, today’s marketers of healthcare markets need to assign a higher priority to market access and reimbursement issues.

Gaining access is more complex and challenging than it was several years ago.  Health plans and providers that pay for healthcare products seek value, not just low cost.  Value is driven by a product’s impact on the quality of care as a function of its cost.  The greater a product’s cost, the greater the improvement in outcomes required.  Adding to the complexity of gaining access, cost is not simply a product’s acquisition cost.  Oh, no.  Cost is the product’s acquisition cost net of any impact on the use of other healthcare products and services.

Payers increasingly require clinical data to document the value a healthcare product delivers.  Peer-reviewed clinical trial data are most valued.  However, at a minimum, some payers will incorporate the results of pilot trials of a new product into their evaluation.

Today, health plans and providers are evaluated based on publicly-reported outcomes measures.  Many health pans and medical groups use the National Commission on Quality Assurance’s (NCQA’s) Healthcare Effectiveness Data and Information Set (HEDIS) data set to publicly report the quality of the care they deliver. Hospitals and some other providers publicly report infection rates, the results of patient satisfaction surveys, Surgical Care Improvement Project (SCIP) and other data.  Healthcare manufacturers can enhance market access by providing data that demonstrate the impact their product can have on the payers’ publicly-reported outcomes measures.

The healthcare delivery system is becoming more integrated, as demonstrated by the formation of accountable care organizations (ACOs) by hospitals, physicians, and other providers.  One reason that this integration effort has a greater likelihood of success than that of the 1990s is that the resulting entities are using publicly reported outcomes and provider compensation models to align incentives.  The greater sense of unity is affecting these payer’s purchasing processes.  Increasingly, hospitals, physicians and other providers are evaluating products in the same way: based on the value they deliver and their impact on reported outcome measures.  These entities are centralizing their purchasing process to further encourage integration, cost savings and improved outcomes.

Payers are driving brand and even product selection.  Through step edits, health plans are specifying which drug classes must be prescribed before others unless the physician files for an exception.  Through formularies, health plans are encouraging physicians to prescribe preferred brand(s) among competitors.  Hospitals as payers are limiting the brands of devices and pharmaceuticals they allow their physicians to order.

On top of these trends, the payer’s world is becoming more complex.  For example, the Affordable Care Act is making individual policy holders and managed Medicaid beneficiaries larger groups to reckon with, along with established commercial and government plans.  The number of organizations that influence payers is growing.   Radiology benefit managers and outsourced specialty pharmaceutical managers are just two of the new influencers of market access and reimbursement.

Healthcare marketers need  to address these complexities to gain access for their products and drive uptake.  These issues need to be addressed early during a product’s development and re-evaluated as development continues to address environmental change and their impact on a product’s market access and reimbursement.

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See some examples of case studies where we use this knowledge to help our customers with gaining market access:

Designing a Next-Generation Product Based off of User-Driven Insights

The Adult Disposable Brief Market — Opportunities for differentiation

Competitive intelligence on a ICU/CCU product’s new feature

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