Published on September 29, 2015
1. www.curo.co.uk Partnership & Collaboration
2. This white paper explores the trends and issues in an evolving EU healthcare environment and looks to draw some conclusions around future options for Partnership and Collaboration between Patients, Payers and Pharma.
3. Collaboration – a new Access paradigm? Europe: divergent and convergent Europe, a vast area covering a mix of diverse cultures, races, viewpoints and outlooks. Separated from Asia by the Ural and Caucasus Mountains, the fact that Europe is a continent is often overlooked, and indeed sometimes the subject of debate. Instead, say the word Europe nowadays and the first thing that springs to mind is the relatively recently formed European Union, the Euro and thoughts of all the benefits and pitfalls this diverse union has brought to its members since the Maastricht Treaty became effective in 1993. Although each member country agrees (to sometimes varying degrees) to be a part of the EU, working together for mutual benefit, whether adopting laws, a new currency, fiscal policies and even bailing out other member governments’ spiraling debts, health care appears to be an area that there is no particular concession or appetite to unify policy. “ ”
4. Differences in European health care systems You just need to look at individual systems in European countries to see how complex uniting health care policy would be – some would argue virtually impossible – and it’s clear that (certainly in the short term) there is little chance of this happening. For example, in Germany the price of a therapy is tied to the additional value it provides over an appropriate comparator. However, in Poland the focus of healthcare providers is to minimise the acquisition cost of therapies so that patients have affordable therapy options and so that there is sufficient supply of therapies for those that need them. Additionally, in the UK, therapies are assessed by their cost-effectiveness (cost per Quality-Adjusted Life Year, QALY) taking into account cost savings that can be seen within the healthcare system (such as the reduction of nurse administration hours) and the therapy that is seen to be most cost-effective will become the standard of care. Sweden also assesses therapies by their cost-effectiveness, however, unlike in the UK, Sweden uses a Value Based Price system, where wider societal costs (such as the care giver burden of a disease) are taken into account. Collaboration – a new Access paradigm?
5. Global trends impacting healthcare systems in 2015 Several global trends will impact all these systems to some degree. People are living longer – the average life expectancy for people living in many European countries is now 80+ and in 2017, 20% of the EU population is expected to be over 65. This aging population requires more long term care for a greater number of conditions and its associated complications - indeed chronic disease now accounts for 70-80% of EU health costs with 80% of older adults having one chronic condition and 50% having at least two. At the same time, the prevalence of certain conditions is increasing due to physicians being better trained in diagnosis (e.g. the number of patients with recorded diagnosis of dementia has increased by over 60% over the last seven years). Moreover, society and the medical community is looking at investing more resources in preventive medicine. And it goes without saying that declining or static birth rates also mean that there will be a smaller working population to fund the care that the society deserves. These demographic changes will lead at some stage to some convergence of healthcare strategies. Collaboration – a new Access paradigm?
6. Collaboration – a new Access paradigm? Budgetary Restrictions As mentioned already (and let’s face it, you’d have to have lived on the moon over the past few years to not know) the spectacular financial crashes of major governments like Greece, Spain, Italy, Portugal and Ireland have all focused minds on levels of spending and spiralling debt. Austerity and cost savings are the order of the day. Whether this approach is the correct one to bring a struggling economy through its worst time is debatable. However, the overall effect is that money is harder to come by, and therefore value for money has become a strategic imperative. Governments have to spend (and in a political environment, seen to be focussed) on goods and services that provide value for money.
7. What is Value? Think about the concept of Value. It’s surprising how many people cannot answer the question “What is value?” Or put another way, you will get a different answer to this question from just about everybody you ask. This rings true to a greater extent within the area of healthcare, where the word “cost” is often wrongly substituted with the word “value”. Perhaps one of the issues today is that cost is easy to measure and is quantifiable, whereas value is always a little trickier to define or justify. It also depends greatly on the level of the stakeholder within the healthcare system: 1. Policy makers, setting overall health care budgets and thresholds but also having to juggle political issues 2. Regional approval or funding bodies, who have to consider the overall budget implications of allowing a therapy to be prescribed 3. Local Payers, who have to carefully manage a restricted budget across a wide variety of services 4. Prescribers, who are faced with the dilemma of wanting to offer better treatment options to their patients but at the same time being restricted by having to adhere to guidelines and formularies 5. Patient associations, who are becoming better informed and organised and therefore are turning out to be a more powerful stakeholder with greater influence on policy makers. Patients are not entering the value argument from a monetary or cost perspective but understandably they just want to have access to the therapies that will treat their condition better and quicker. Collaboration – a new Access paradigm?
8. Greater patient pressure The growth of the internet has undoubtedly made fundamental changes to people’s lives over the last 20 years. It has become a provider of information to the general public on a scale that would have been previously unthinkable. For some patients this means more “self-diagnosing.” For others it means a greater knowledge about all treatment alternatives. Information available to patients on the web could be viewed as both a positive and negative development, but it cannot or should not be discounted. If we put aside the potential misinformation that the patients are exposed to and possibility of information being misused, it remains indisputable that, with this sudden availability of information from scientific studies and drug trials to patient chat rooms, patients have never before been better informed. Indeed, it is reported that patients are even taking it upon themselves to set up their own drug trials, coordinated via Internet patient sites, when they feel that the usual treatment pathways are exhausted. It has to be considered therefore that more pressure will be applied initially to prescribers and local Payers (and ultimately also to larger health bodies and politicians) to provide a wider, more varied range of treatment options. Collaboration – a new Access paradigm? “ ”
9. Why does innovation matter? Payers face the seemingly impossible task of try to achieve better outcomes for a growing population with a flat budget. The obvious solution is to spend less on drugs. Right? Wrong. Let’s look at Type 2 Diabetes (T2D). This is a hugely complex disease where approximately 10% of costs are spent on pharmacotherapies. 90% of costs are incurred in general disease management (clinics, AE, comorbidities etc.) It is easy to target the 10% drug cost because it is a discreet and measurable area of spend. The 90% disease management cost seems like a very complex area to tackle so why bother? The counter position is that more effective use of new innovative T2D diabetes drugs (SGLT2 and GLP-1 and DPP-4 etc.) will delay progression to insulin where the majority of T2D costs are incurred. In other words, spending more on innovations will improve downstream disease management costs and mean that overall, more patients can be managed for the same budget – even if the 10% spend on drugs is increased. In other words, innovative drugs are not part of the problem, they are part of the solution. Collaboration – a new Access paradigm?
10. The Conundrum Patients want access to the latest health innovations. Healthcare systems are prepared to grant this access provided the concept of value has been effectively addressed – and perhaps innovations will drive more effective disease management strategies. Pharma needs to be rewarded on a commercial basis for investment in innovation – and in turn this supports further innovation. Given this mutual aspiration to common goals around access to innovative therapies, why is access such a struggle? Why don’t patients get access? Why do Payers feel that therapies are too costly? Why does Pharma have to do deals that address the cost and not the value of a therapy? The answer would appear to be a lack of collaboration and trust. A focus on short-term measures and a history of adversarial engagement which further entrenches the differences in the aims of each party, rather than building on a set of common mutually beneficial aims. Collaboration – a new Access paradigm?
11. Collaboration - An approach for the future Despite some European countries such as Poland opting for a cost-minimisation approach, generally speaking, the need to prove the value of a therapy is becoming increasingly necessary for both Pharma companies and health care funding bodies. Increased need for access to therapies will put greater pressure on health care providers, driven by a growing ageing population and better informed patients who are savvier to the whole health care system and all the possible treatment options available not just within their own countries, but advances in therapies across the globe. Collaboration between Pharma, health care bodies and patients is surely one of the key steps to enabling a more focused, value driven approach to health care and patient treatment. There has been a great deal of progress made over the recent past in terms of a collaborative approach primarily between Pharma and funders. Multiple innovative value-based approaches have been implemented across countries and can be classified in two types: financially-based or outcome-based. Within Europe, the UK and Italy are the two countries with more experience in Risk Sharing Schemes (RSS). Collaboration – a new Access paradigm?
12. Collaboration - An approach for the future In the UK, numerous agreements have been negotiated with the Department of Health to deal with treatments that do not deliver the anticipated benefits. In Italy, the most common type of agreement for oncology therapies is the Payment by Results Scheme. This ensures that the Italian health system pays only for a treatment where there has been a positive response. Treatment is discontinued for non-responders and related therapeutic costs are borne by the manufacturers. Other countries are increasingly implementing similar schemes. For example, Spanish health authorities recently negotiated a pricing agreement for Hepatitis C anti-viral drugs, enabling greater patient access. Collaboration – a new Access paradigm?
13. Patient Support Pharma needs to have a positive impact on a therapy’s success by providing the additional support that a patient may need. The days of saying goodbye to a patient as they walk out of the door with their prescription should be gone. And it is not just about providing information to the patient. It´s about support in broader terms and it should be on-going. From adherence programs (SMS reminders) to adjunctive services (e.g. dietary advice in T2D) and even monitoring packages (on-line diaries), offering support to patients can help keep them on track and be more in control of their condition. Collaboration – a new Access paradigm? Patient Support Prescription Adjunctive Services Monitoring Packages Adherence Programs
14. Support, Efficacy and RWE – driving results and capturing evidence Patient support programs clearly drive improved adherence and efficacy but they also provide a further option for gathering RWE which will help Payers to see the actual impact of a therapy in a given population. We all know the theory that improved adherence will result in reduced BOD, improved clinical outcomes and an ensuing improvement in disease management economics. If Pharma and health systems can collaborate to fund, set up and manage on-going support for patients, the information provided will support the goals of both parties – and of course, patients! But this support is not achieved by giving out a leaflet or posting a website. This is about a firm commitment of all the stakeholders to achieve patient-centred care with a more holistic approach, covering all contributing factors that may help a therapy work better. Collaboration – a new Access paradigm?
15. The pharma industry can use technology to offer an advanced collaboration and give their patients the support that they need. Recently for example, a Pharma company has put in place a reporting system for users of an intravenous treatment that allows more patients to be moved from hospital to home to receive their ongoing infusions. Patients access a diary using their mobile phones and complete questionnaires about their treatment progress and quality of life. Collaboration – a new Access paradigm? Clinicians can also access this information remotely to monitor patients and arrange a visit if necessary, ensuring more time is made available to support complex cases; this clearly alleviates some of the everyday pressures on hospitals and clinics. Another recent example is a partnership between a Pharma company and a worldwide provider of mobile telecommunications to offer mHealth services. This collaboration will create new mobile and internet-based services to support patients through their treatment journey, improving medication adherence and giving them confidence to manage their condition more effectively. Support, Efficacy and RWE – driving results and capturing evidence
16. Summary Patients are better informed than ever before and their needs and expectations are growing. Health systems are looking to achieve the same or better outcomes with a growing population and flat budgets. Pharma is looking to innovate but also to get a fair return for such innovations. Collaboration – a new Access paradigm? If policy makers, Pharma and patients collaborate more effectively - around in-market beyond the pill solutions - the information generated, the outcomes achieved and the access secured will evolve into a benign circle of value based access, rewarded innovation and improved healthcare provision. Even in a growing and ageing population. Current mechanics to access are geared towards restriction and cost containment.
17. Key Contributors: Chris O’Neill, CEO With a background in sales and consulting, Chris prides himself on his ability to bring a fresh approach to solving sometimes long-standing complex and highly problematic MA challenges. Jonathan Mowll, Chairman Jonathan has a wealth of blue-chip business experience, and is an accomplished Management Consultant, building partnerships with industry leaders across a range of sectors to formulate and execute strategy. Goretti Saumell, Senior Consultant Goretti has considerable experience within the Pharma industry, having held a variety of posts within Health Care sales in Spain and most recently as a Specialist Clinical Pharmacist in the UK. Key Contributors Contact Us We specialise in enabling you to speak to your Payers ‘in their language’, ensuring that your MA strategy answers the right questions, in the right way, and at the right time. Contact us today to find out how we can help drive your Market Access success.
18. Curo is a global Market Access consultancy and communications agency. We work with the pharmaceutical industry and healthcare funding bodies (Payers) to enable an innovative and collaborative approach to Market Access for new therapies. Curo can enable you to formulate a solid Market Access strategy by offering honest perspectives on evidence and value. Working with your HEOR data, our analysts can help you to understand the real-world impact of your therapy in a given disease area. Curo helps you to create a narrative that means much more than just numbers on a spreadsheet – we breathe life into your data.
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