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Research & Reports

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Acute Coronary Syndrome | Access & Reimbursement | Detailed, Expanded Analysis (US)

Acute Coronary Syndrome | Access & Reimbursement | Detailed, Expanded Analysis (US)

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Introduction: This research explores the reimbursement and utilization landscape for acute coronary syndrome (ACS) drugs and the impact of accountable care organizations (ACOs) on payers’ and cardiologists’ decision-making. ACOs are provider organizations that manage the full continuum of care and take accountability for the total costs and quality of care for a defined patient population. ACS is a condition whose treatment can benefit from the integrated, patient-centered, evidence-based care practiced within ACOs and for which the goal of cost-effective treatment can influence prescribing.

Questions Answered in This Report:

  • Generic clopidogrel dominates antiplatelet treatment of ACS, but Brilinta’s superior clinical profile has helped it gain patient share despite its higher price and greater restrictions. How is prescribing different for ACS in the ACO environment? How do cardiologists regard the various agents? How do MCO restrictions affect utilization?
  • Two relatively new PCSK9 inhibitors—Repatha and Praluent—will probably have their labels expanded to secondary prevention of ACS. What is their use currently in this indication? How are MCOs likely to cover these drugs for this indication? Which of them is likely to have an advantage?
  • ACOs are expected to take on more risk in terms of the medical and pharmacy costs of their patients. What formularies do ACO physicians commonly use for ACS patients? When do MCOs expect to require ACOs to take on risk? How many ACOs have their own dedicated formularies?

Scope:

  • Markets covered: United States.
  • Methodology: Surveys of 100 cardiologists and 30 managed care organization (MCO) officials, including 14 pharmacy directors and 16 medical directors, in January 2017.
  • Indication coverage: Acute coronary syndrome (ACS).
  • Key Drugs covered: Brilinta, clopidogrel, Effient, Plavix, Praluent, Repatha, Vascepa, Zontivity.
  • Key companies mentioned:  Amgen, AstraZeneca, Eli Lilly, Merck, Sanofi.

Table of contents

  • Detailed, Expanded Analysis (US)
    • Key Updates
      • August 2017
      • April 2017
    • Market Access Overview
      • Overview of Market Access in Acute Cardiovascular Syndrome
    • Actionable Recommendations to Optimize Market Access
    • Successes and Stumbles
      • Overview of Successes & Stumbles for ACS
      • Successes Among ACS Therapies in the United States: Physicians
      • Stumbles Among ACS Therapies in the United States: Physicians
      • Successes Among ACS Therapies in the United States: MCOs
      • Stumbles Among ACS Therapies in the United States: MCOs
    • Key Stakeholders in the Road to Market Access
      • U.S. Stakeholder Dynamics in the Road to Reimbursement
      • Healthcare Coverage in the United States
      • 2017 DRG Data on ACOs
    • Key Market Access Roadblocks
    • Reimbursement Dynamics
      • United States: Commercial Managed Care Organizations
        • Reimbursement Summary
        • Pricing, Reimbursement, and Value Drivers for ACS
        • Cost-Sharing and Restrictions
        • ACO Involvement by MCOs
    • Pricing and Reimbursement, Policy, and Coverage: Impact on Prescribing
      • Patient Share in Key Payer Channel
        • Key Findings
        • Treatment Decision Drivers
      • Prescriber Preference
        • Prescriber Preferences for Antiplatelet Therapies in ACS
      • Impact of Restrictions on Prescribing
        • Impact of Payer Policy on Prescribing: Key Findings
      • ACO Impacts
        • Impact of ACOs on the Reimbursement of ACS Drugs
    • Market Access Landscape for Emerging Therapies
      • Impact of Emerging Therapies on Prescribing
        • Likely Impact of Emerging Therapies for Acute Coronary Syndrome
      • Potential Placement of Emerging Therapies at Various Prices
        • Potential Reimbursement of Emerging Therapies for ACS
      • Prescriber and MCO Priorities for Emerging Therapy Evaluation
        • Key Findings
    • Methodology
      • Primary Market Research Methodology: Physicians
        • Physician Demographics
      • Primary Market Research Methodology: MCOs
        • MCO Demographics
    • Appendix
      • Physician Survey
      • MCO Survey

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  • Pub Date: August 2017
  • Author(s): Paula Wade
  • Paula Wade tracks and analyses the national trends in the health insurance industry for Decision Resources Group. She produces the company’s Managed Care Organization Analyzer products and has authored several of DRG’s Physician Payer Dynamics reports. A former newspaper journalist with a background in survey research, Ms. Wade has also worked in healthcare advocacy and for the Tennessee Department of Commerce and Insurance.

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