Facing a dramatic rise in expenditures for cancer therapies, U.S. healthcare payers are increasingly assessing the value of drugs relative to their prices, taking into account attributes such as survival, disease burden, toxicity, patient preference, and impact on overall healthcare costs. Treatment of advanced, metastasized breast cancer has challenged payers because of the complexity and high cost of regimens, such as Genentech’s Perjeta/Herceptin in combination with docetaxel as a first-line treatment for metastatic HER2+ breast cancer. Several value assessment models have emerged to help managed care organizations (MCOs) determine the value, including the cost-effectiveness, of therapies. As payment reform intensifies, understanding the effect of value assessment on MCOs’ reimbursement decisions is critical to a sound market access strategy for drugs launching for breast cancer and other diseases.

Questions answered

  • How common is MCOs’ application of value assessment in determining coverage of breast cancer drugs on commercial plan formularies?
  • Which value assessment models will MCOs likely use to evaluate new breast cancer therapies, and what will be the likely effect on coverage policies and, ultimately, on oncologists’ prescribing decisions?
  • What attributes of a breast cancer drug do payers and oncologists value most highly?
  • What role do value assessments play in pay-for-value initiatives such as outcomes-based contracting and indication-specific pricing?
  • How do payers view cost-effectiveness metrics for specific breast cancer populations versus oncology as a whole and other therapy areas?

PRODUCT DESCRIPTION

Access & Reimbursement: Provides in-depth insight regarding the impact of payer policy on physician prescribing behavior so that companies can build a market access strategy and optimize their brand positioning.

Table of contents

  • Detailed Expanded Analysis: The influence of value assessment models (US)
    • Market Access Overview
    • Actionable Recommendations to Optimize Market Access
    • Successes and Stumbles
      • Overview of Successes & Stumbles for Breast Cancer
      • Successes Among Breast Cancer Therapies in the United States: Physicians
      • Stumbles Among Breast Cancer Therapies in the United States: Physicians
      • Successes Among Breast Cancer Drugs in the United States: MCOs
      • Stumbles Among Breast Cancer Therapies in the United States: MCOs
    • Key Stakeholders in the Road to Market Access
      • United States: Stakeholder Dynamics in the Road to Reimbursement
      • Healthcare Coverage in the United States
    • Key Market Access Roadblocks
    • Reimbursement Dynamics
      • United States: Commercial Managed Care Organizations
        • Reimbursement Summary
        • Pricing, Reimbursement, and Value Drivers for #INDICATION#
        • Cost-Sharing and Restrictions
        • Pricing, Reimbursement, and Value Drivers for Breast Cancer Drugs
    • Pricing and Reimbursement, Policy, and Coverage: Impact on Prescribing
      • Patient Share in Key Payer Channel
        • Key Findings
        • Treatment Decision Drivers
      • Implications of Value Assessments for Physicians
        • Key Findings
      • Impact of Restrictions on Prescribing
        • Impact of Payer Policies on Prescribing: Key Findings
    • Market Access Landscape for Emerging Therapies
      • Potential Placement of Emerging Therapy at Various Prices
      • Impact of Emerging Therapies on Prescribing
        • Likely Impact of Emerging Therapies for Breast Cancer
      • 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

Author(s): Chris Lewis; Aarushi Kashyap, M.Tech

Chris Lewis serves as primary research manager, Access and Reimbursement, with responsibility for coordination, content review and content generation of the market access and reimbursement insights at DRG. Content is based on online surveys of managed care organizations and physicians and expert analysis of reimbursement and prescribing patterns of key therapies treating various disease states. Lewis was an analyst/senior analyst for the group’s HealthLeaders-InterStudy subsidiary for eight years, specializing in the managed care and pharmacy benefit management industries. Throughout her tenure, she has produced the Health Plan Analysis reports for California, New York, New Jersey, Connecticut, and Pennsylvania and authored DRG’s series of pharmacy benefit manager profiles. She has also conducted numerous webinars for the group. She is a seasoned journalist with a in communications from California State University, Sacramento.

Aarushi Kashyap is a Senior Insights Analyst in Oncology team at Decision Resources Group, based out of Gurgaon office in India. She comes with a work experience of 4 years as Business Analyst with practice across multiple oncology indications in various functions in Competitive Intelligence and Secondary Research, including pipeline analysis, competitive product reporting, clinical trials assessment and benchmarking, clinical and competitor landscaping, therapy area deep dive reporting, ad-hoc news tracking etc. She has attended various big and small oncology medical congresses across US and Europe in parallel to creating pre- and post-conference data summaries with implications and schedule trackers for abstracts of interest delivering to directly to clients. She has earned her Master's and Bachelor's in Technology in Biotechnology from Jaypee Institute of Information Technology University.


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