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

  • Breast Cancer - Access & Reimbursement - Detailed Expanded Analysis: The Influence Of Value Assessment Models (US)
    • 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
        • Best-Performing HER2+ Drug in Terms of Clinical Attributes
        • Best-Performing HER2+ Drug in Terms of Market Access Themes
        • Best-Performing HR+/HER2- Drug in Terms of Clinical Attributes
        • Best-Performing HR+/HER2- Drug in Terms of Market Access Themes
        • 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
        • Healthcare Coverage in the United States
        • Major Commercial Insurers in the United States
      • Key Market Access Roadblocks
        • Reimbursement Dynamics
          • United States: Commercial Managed Care Organizations
            • Lessons Learned and Key Takeaways
            • Current Reimbursement of Select Therapies Treating Breast Cancer
            • Reimbursement of Key Therapies Treating Breast Cancer in 12 Months' Time
        • Pricing and Reimbursement, Policy, and Coverage: Impact on Prescribing
          • Patient Share in Key Payer Channel
            • Key Findings
            • Commercial Patient Share of HER2+ Breast Cancer Drugs
            • Commercial Patient Share for HR+/HER2- Breast Cancer Drugs
            • Percentage of Commercially Insured Patients Receiving Chemotherapy for HR+/HER2- Breast Cancer
            • Treatment Decision Drivers
            • Clinical Factors Influencing Choice of Advanced/Metastatic Breast Cancer Drugs
            • Economic and Nonclinical Factors Influencing Choice of Advanced/Metastatic Breast Cancer Drugs
            • Resources Guiding Oncologists' Breast Cancer Treatment Decisions
        • Market Access Landscape for Emerging Therapies
          • Potential Placement of Emerging Therapy at Various Prices
            • MCOs' Awareness and Analysis of Select Emerging Therapies for HR+/HER2- Breast Cancer
            • MCOs' Perceived Value of Select Emerging Therapies for HR+/HER2- Breast Cancer
            • MCOs: Most Promising Emerging Therapy for HR+/HER2- Breast Cancer
            • Potential Formulary Placement of Margetuximab
        • Methodology
          • Primary Market Research Methodology: Physicians
            • Number of Years in Practice Postresidency
            • Mean Number of Years in Practice Postresidency
            • Average Number of HER2+ and HR+/HER2- Breast Cancer Patients Under Management
            • Drugs Prescribed for Metastatic/Advanced HER2+ Breast Cancer
            • Drugs Prescribed for Metastatic/Advanced HR+/HER2- Breast Cancer
            • Distribution of Medial Practice by Region
            • Distribution of Medical Practice by States in Northeast Region
            • Insurance Coverage of Surveyed Oncologists' Breast Cancer Patients
          • Primary Market Research Methodology - MCOs
            • Percentage of MCO PDs vs. MDs
            • Types of Plans Offered by Surveyed MCOs
            • Distribution of MCOs by Region
            • MCO Distribution by State
            • Operations of MCOs: National, Regional, or Single State
            • Range of Number of Lives Served by MCOs
            • Average Number of Lives Managed by MCOs
            • MCO vs. PBM Control of the Formulary and Pharmaceutical Contracting
            • Degree of Customization of PBM Formulary
        • Appendix
          • Physician Survey
            • Practice Setting of Surveyed Oncologists
            • Practice Ownership Structure of Surveyed Oncologists
            • Staff Size of Independent, Community-Based Oncology Practices
            • Oncologists' Mean Level of Agreement on the Value Discussion with Patients
            • Indications in Which Oncology Practices Have Conducted Pharmacoeconomic Studies
            • Oncologists' Awareness of and Use of NCCN's Evidence Blocks
            • Level of Influence of NCCN's Evidence Blocks on Oncologists' Prescribing Decisions
            • Future Level of Influence of NCCN's Evidence Blocks on Oncologists' Prescribing Decisions
            • Weight of Importance of Evidence Blocks Attributes to a Value Determination
            • Oncologists' Awareness of and Use of ASCO's Value Framework
            • Level of Influence of ASCO's Value Framework
            • Impact of ASCO's Value Framework on Breast Cancer Drugs
            • Likelihood of Using ASCO's Value Framework to Guide Breast Cancer Treatment
            • Factors That Would Prompt Oncologists' Use of ASCO's Value Framework
            • Future Impact of an ASCO Net Health Benefit Score on Breast Cancer Drug Prescribing
            • Oncologists' Use of DrugAbacus and of ICER's Value Assessment Tools
            • Level of Confidence in Value Assessment Tools
            • Oncologists' Use of Clinical Pathways for Breast Cancer Drugs
            • Entities Responsible for Developing Clinical Pathways Programs for Breast Cancer, as Reported by Oncologists
            • Oncologist-Reported Role of Value Assessments in a Cancer Drug's Inclusion in Clinical Pathways
            • Impact of Clinical Pathways on Oncologists' Prescribing
            • Most Important Factors Influencing Choice of Emerging Therapy for HR+/HER2- Breast Cancer
          • MCO Survey
            • Influence of P&T Committee Members on Formulary Decisions for Breast Cancer Drugs
            • Time Frame for Formulary Decision Making
            • MCO Status of Review for Kisqali
            • Interim Status Assigned to Breast Cancer Drugs Not Yet Reviewed for Formulary
            • MCO Request of the AMCP Dossier for Product Formulary Review Submissions
            • MCO Preference for Pharmacoeconomic Data in Dossier Submissions
            • Use of Preferred and Nonpreferred Tiering for Traditional and Specialty Drugs
            • MCOs That Are Switching to a Preferential Tiering Structure in 12 Months
            • Allowance of Medical Benefit Coverage for Breast Cancer Drugs on Pharmacy Benefit
            • Average Coinsurance for Breast Cancer Drugs Covered on a Specialty Tier
            • Average Copays for Breast Cancer Drugs Covered on a Specialty Tier
            • Out-of-Pocket Caps for Members Paying Coinsurance
            • Implications of Drug Placement on a Specialty Tier
            • Utilization Management Controls on HER2+ Breast Cancer Therapies
            • Utilization Management Controls on HR+/HER2- Breast Cancer Drugs
            • Types of Contracts Covering Select Branded Breast Cancer Therapies
            • MCO-Reported Degree of Concern About Budget Impact of Breast Cancer Drugs
            • Mean Level of Concern About Budget Impacts from Breast Cancer Drugs
            • MCO-Determined Cost-Effectiveness of Branded Breast Cancer Drugs
            • Highest Accepted Incremental Cost-Effectiveness Ratio per Quality-Adjusted Life-Year for Breast Cancer Drugs
            • Breast Cancer Drugs Examined by a Cost Utility Model
            • MCO Use of DrugAbacus and Evidence Blocks for Breast Cancer Therapy Evaluation
            • Perceived Potential of Value Assessment Tools to Reduce Drug Prices
            • Influence of Third-Party Value Assessment Tools on Cancer Therapy Coverage Policy
            • MCO Communication with Network Oncologists About Value Assessments
            • Impact of Value Assessment Discussions on Oncologists' Prescribing Behavior
            • Breast Cancer Therapies for Which Manufacturers Have Submitted Pharmacoeconomic Data
            • Quality of PE Data Submitted for Breast Cancer Therapies
            • Effects of Positive PE Data on Coverage of Key Branded Breast Cancer Therapies
            • MCO-Reported Best-Performing HER2+ Breast Cancer Drugs
            • MCO-Reported Best-Performing HR+/HER2- Breast Cancer Drugs
            • Value Assessments of Drugs with Market Experience
            • Sources of Information Used in a Value Assessment
            • MCOs' Use of Clinical Pathway Programs for Breast Cancer Drugs
            • Entities Responsible for Developing Clinical Pathways Programs for Breast Cancer, as Reported by MCOs
            • Implications of Clinical Pathways Programs
            • MCO-Reported Role of Value Assessments in a Cancer Drug's Inclusion in Clinical Pathways
            • Stage of Drug Development When MCOs Start Scanning Horizon for Emerging Therapies
            • Stage of Drug Development When MCOs Do Value Assessments
            • Most Compelling Types of Pharmacoeconomic Data

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

      Chris Lewis serves as primary research manager, U.S. 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 B.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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