Key Role of Managed Markets in the Future of Pharma

8/10/2019 Key Role of Managed Markets in the Future of Pharma

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Kent Rogers

Vice President Managed Markets

ACORDA

Therapeutics, Inc.


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! How has the role of Managed Markets changed over the

last decade?

! How do differences between large and small pharma

organizational structures impact Managed Markets?

! Whats in store for Managed Markets?


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Source: Health Strategies Group


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" The two most

important stakeholders

are the CMS and

private payers

" MCOs dominate private

healthcare provision and

now cover 95% of

employees


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MCO

SpecialtyPharmacy

PBM

Wholesaler

MCO

PBM

Retail

Wholesaler

PBM

Retail

PBM

SpecialtyPharmacy


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WarehousingRetailChain

SpecialtyDistributors

Chain Drug Store

Mail OrderPharmacy

Food/Mass MerchDrug Store

Independent

Drug Store

HHC

Long Term Care

Acute CareHospital Pharmacy

HMO

Government

Physician

Clinic

SPP

ManufacturerDistributionC

enters

Patient

HealthCareProfessional

Full LineWholesalers

MailMedical Groups

VA & DoD

Prisons


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Bergen Brunswig Drug Co.Trent Drugs Ltd.

Alco Health Services Corp.

C.D. Smith Healthcare Inc.General Drug CompanyJames Brudnick Company Inc.Walker Drug Company

Albers, Inc.Coleman, Meadows, Pate Drug Co.Skyland Medical Supply, Inc.Gulf DistributionNewbro Drug CompanyEagle Drugs Inc.J.M. BlancoDr. T.C. Smith CompanyDurr Drug Company, Inc.Owens and Minor Inc.South Bend Drug Co.

F. Dohmen & Co.Par MedBindley Western Drug Company

Tennessee Wholesale DrugAlabama Wholesale DrugSuperior Wholesale DrugKendall DrugJ.E. Gould & Co.Behrens, Inc.Humiston-KneelingWhitmire Distribution Corp.Solomons Company Inc.Chapman Drug Co.

D&K Healthcare ResourcesMedis Health & Pharmaceutical ServiceV.F. Grace, Inc.FoxMeyer CorporationHarris Wholesale

McKesson Drug Company

Cardinal

AmeriSource Bergen

0 200 400 600 800 1,000 1,200

F. Dohmen

Walsh Dohmen

Smith Drug Co.

H.D. Smith Wholesale Drug Co.

D&K Wholesale Drug Inc.

Kinray Inc.

Morris + Dickson Co. Ltd.

Sales $ Millions

AmeriSource Bergen

Cardinal

McKesson Drug Company


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Managed

Markets

Senior

care

Medicaid

MCOs:

Health Plans/

PBMs/PDPs

Prisons

Hospitals

Large Group

Practices

Behavioral

Health

VA/DOD

GPOs

IHNsUnions

Pricing

Houses

Employers

Trade


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2: Prioritize Accounts1: Identify Segment Targets

CEO

President CFO

VPProvider

Relations

VPClinical

Operations

Legal

ContractingVPMarketing

VPPublic

RelationsVPQuality

Admin

Assistant

Medical

Directors

Pharmacy

DirectorAccount

Executives

(HMO)

Provider

Contracting

Hospital

Contracting

Account

Executives

(PPO)

Staff

PharmacistActuary

PBM Client

Director

Public

Relations

Lobbyist

Outcomes Director

Case

Manager

3: Determine Contact Depth

Level 2 Accounts

Tier Differentials > $15

Co-Insurance Tiers

PAs/Step Edits

Regional/NationalInfluence

Level 1 Accounts


Co-Insurance Tiers

PAs/Step Edits


Level 4 Accounts



Level 3 Accounts

Tier Differentials < $15


Step Edits

Formulary

Control

Prescription Volume

Hi

Low

Low

Hi

MCOs

PBMs

Hospitals Wholesalers

GPOs

SPPs


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CEO

President CFO

VP ProviderRelations

VP ClinicalOperations

LegalContracting

VP MarketingVP PublicRelations

VP Quality

AdminAssistant

MedicalDirectors

PharmacyDirector

AccountExecutives

(HMO)

ProviderContracting

HospitalContracting

AccountExecutives

(PPO)

StaffPharmacist

ActuaryPBM Client

Director

PublicRelations

Lobbyist

Outcomes Director

CaseManager


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CEO

President CFO

VP ProviderRelations

VP ClinicalOperations

LegalContracting

VP MarketingVP PublicRelations

VP Quality

AdminAssistant

MedicalDirectors

PharmacyDirector

AccountExecutives

(HMO)

ProviderContracting

HospitalContracting

AccountExecutives

(PPO)

StaffPharmacist

ActuaryPBM Client

Director

PublicRelations

Lobbyist

Outcomes Director

CaseManager


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Active Account Planning


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Thresholds may be evident when the price goes above $400 and $700 WAC per month.

2nd tier

3rd tier

4th tier


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Payer

Strategy

Build the

ValueProposition

Prime PayerMarket

DevelopDistribution

Strategy

DevelopPricing

Strategy


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CEO

CFO CMO COO

Marketing

ManagedMarkets

Sales

GeneralCounsel


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CEO

CFO CMO COO

Marketing SalesManagedMarkets

GeneralCounsel


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CEO

CFO CMO CCO

Marketing

Sales

ManagedMarkets

General

Counsel


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CEO

CFO CMO CCO

MarketingManagedMarkets

Sales

GeneralCounsel


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ManagedMarkets

National MCOs/PBM

GPOs/Hospitals

Regional MCOs/PBMs

Payer Contracting

GovernmentAffairs

Product Pricing


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National Committee forQuality Assurance (NCQA)

URAC (Utilization ReviewAccreditation Commission)

Pharmacy Quality Alliance(PQA)

National Quality Forum

(NQF)

Joint CommissionAccreditation of HealthcareOrganizations (JCAHO)

AMA Physician Consortiumfor PerformanceImprovement

National Quality Forum(NQF)

Ambulatory QualityAlliance (AQA)

Hospital Quality Alliance(HQA)

Pharmacy Quality Alliance

(PQA)

NCQA-HEDIS*

Bridges to Excellence

Integrated Healthcare

Association

Hospital Compare

Medicare Physician

Voluntary ReportingProgram (PVRP), nowPQRI

HHS Value-Driven

Health Care Initiative


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! Increase in Federally Mandated Rebates 15.1% to23.1%! Medicaid Eligibility will be expanded

! Medicare Part D Donut Hole 50% share! Changes to the definition of AMP resulting in a Higher AMP

! PHS Program participation will expand FederalCeiling Price legislation


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ManagedMarkets

NationalMCOs/PBM

GPOs/Hospitals

Regional

MCOs/PBMs

PayerMarketing

Trade &Distribution

PayerContracting

ProductPricing HEOR

BusinessDevelopment

Public

Policy


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CEO

CRO

VP Accounts

VP Contracts/

Pricing

VP Trade/

Distribution

CFO CMO CCO

Marketing Sales

General

Counsel


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! Managed Markets experiencing increasing control over

levers of corporate revenue

! Span of responsibility for Managed Markets departmentsexpanding with the changing healthcare environment

! Both large and small pharma organizations need to adapt

their organizational structure to accommodate these changes

Key Role of Managed Markets in the Future of Pharma

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