Do you ever consider your medical practice as part of the healthcare “market?”
If not, you should start. Why?
Because payers look at you that way…
And payers represent a lot of your practice income!
Definition of “Market Access”
What do we mean by “market access?”
Market access is defined as the process to ensure that all appropriate patients who would benefit, get rapid and maintained access to the brand, at the right price.
This has been an increasing focus for drug manufacturers for decades. They view market access as the green light from a given payer to sell their product to that health plan’s membership.
As you can imagine, they invest heavily in making sure their products get “access” to health plans’ memberships to even have the opportunity to sell their product to those members.
Drug companies have entire groups within their ranks that are solely focused on making sure their products get favorable coverage decisions by payers. They understand that if a product is not covered (or poorly covered) by a given health insurer, that plan’s membership is highly unlikely to actually spend their own money on the full price of the medication.
How do they do this?
Quite simply, it comes down to a couple of key constructs: 1) data, 2) communication, and 3) contracting.
First, manufacturers rely heavily on the clinical data, health economics and outcomes research data, and quality of life data associated with their products to persuade the payer of the value their products bring. Often, these data will highlight that an investment in their products results in some advantages in other places in their overall spend (e.g., fewer hospitalizations for a cholesterol medication).
Secondly, communication is crucial, and often over-looked. While marketing to payers is different than marketing to consumers (i.e., TV commercials), there is a level of packaging data for an effective presentation that highlights the value of the data associated with a product in a compelling way.
Finally, contracting is employed, especially within crowded markets with similar products that are poorly differentiated by their data. Poor or limited differentiation of products in effect allows the payer to drive the conversation to a simple cost comparison, inviting the need for product discounting by manufacturers for any kind of preferential treatment.
Growing Importance of Market Access to the Practice Owner
So why does this all matter to the practice owner?
Because market access is controlled by payers… and your practice income is largely controlled by payers.
Your ability to generate a data-driven value proposition, and then deliver that in a compelling way is critical. With the current market dynamics, it is becoming more and more critical. Payers are looking to network with only the best physician groups. That means those groups that have proven return on their investment in healthcare services spending.
Accountable Care Organizations (ACOs) are an important and practical illustration of this trend. These groups are networking with payers around pre-specified goals to deliver value in the greater healthcare delivery network they develop. The goal is overall higher quality and a lower price for the payer.
The 2010 Affordable Care Act (ACA) created two significant ACO initiatives. The first was the Medicare Pioneer program. The Pioneer program was an invitation-only program in which specific health delivery networks were invited into a “shared savings” contract with the Centers for Medicare & Medicaid Services (CMS). Ostensibly, these integrated networks could identify opportunities to reduce overall healthcare spending on their Medicare patients. At the end of each year, CMS would split the difference in savings from the prior year. Interestingly, while 32 organizations started the program, only 23 still remain following the release of the first batch of data. (See http://innovation.cms.gov/initiatives/Pioneer-ACO-Model/ for more information)
The second was the Medicare Shared Savings Program (MSSP). The MSSP was open to any ACO entity who organized and was interested. In general, MSSP comprised 33 quality metrics in exchange for splitting the savings with CMS (See https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/index.html?redirect for more information).