It’s no secret that the world of healthcare and pharmaceuticals is complex (to put it lightly). And the niche markets in the industry of rare disease, oncology, and cell and gene therapies are no exception. All over the U.S., payer trends, insurance policies, legislation, and drug affordability shift and swirl in a kind of complicated dance.
Staying on top of the ever-changing atmosphere is crucial if a biopharma manufacturer wants to succeed. Adding even more layers to the healthcare landscape are business health coalitions and their role in shaping specialty drug coverage. This warrants a deep dive into how coalitions are influencing rare disease pharmaceuticals. We’ve pinpointed five essential takeaways you need to know.
Let’s start with the basics. What’s a business health coalition anyway?
Business health coalitions are partnerships that create large conglomerates of employer groups for the purposes of:
- Group purchasing of benefits or other supplies
- Growing collective knowledge
- Solving common issues
- Expanding professional networks
Developed at the regional and national level, these coalitions come in big and small packages covering anywhere from thousands to millions of members. Their inherent focuses are on managing benefits and addressing healthcare costs faced by employers.
As a biopharma manufacturer, it’s imperative to understand how these coalitions influence specialty drug coverage and whether you should get involved or steer clear. The real challenge is knowing where and when participating in a business health coalition is going to be a symbiotic, worthwhile relationship.
1. Get to know a coalition’s board members, programs, initiatives, and transparency to help determine if it’s a good fit for your business.
Like with any business endeavor, some initiatives are worth the time and focus, and others are not. Business health coalitions aren’t much different—some are worthwhile and others deserve a hard pass. To help determine the difference, make note of the other industry voices at the table and go through a quick checklist for determining a good fit.
- Is the employer group even receptive to industry voices as commercial members or partners?
- Is the employer group action-oriented themselves, or are they more reliant on other groups for resources that might come from the national level?
- Does the group’s size and demographic overlap with your patient population in a meaningful way?
- What are other manufacturers doing to address health challenges at the group level?
- What do you bring to the table for addressing healthcare costs?
- Do you have opportunities for aiding in prevention or early detection?
In short, do your due diligence before pursuing an active role in any coalition. And if you have any ethical concerns about coalition agendas, keep in mind that many of these organizations are on the up-and-up and genuinely want to create better education and access to healthcare. By doing your homework and talking to people you trust, you can find the well-intentioned business health coalitions that are most aligned with your goals.
2. Getting your voice heard is important for educating government and policy leaders.
Joining a coalition’s board or even just joining as a corporate member gives your industry and organization a seat at the table. With that seat, you can use your voice to help other leaders understand not only the competitive value or solutions you have to offer but also why your mission matters to employer groups.
Even before the current labor shortage, many employers faced challenges hiring and retaining talent, causing them to create more competitive benefits packages. While that’s great for employees, these alluring benefits might overextend an employer to the point they become hyper-focused on driving down costs. How can you help in this situation? Your guiding voice can prevent these well-meaning employer groups from joining the jelly-of-the-month club version of pharmacy benefits, giving patients better access to expensive therapies.
Think of it this way: if you don’t take a seat at the table, someone else with a different agenda will.
3. Biopharma industry leaders join coalitions to be a part of the bigger conversation.
So, what kinds of roles do drug manufacturers take as part of a business health coalition? Many times drug makers fund educational resources like patient toolkits on managing population health or for a specific common disease type. For example, Genentech/Roche and Amgen financed the Midwest Business Group on Health’s robust hemophilia and migraine toolkits, respectively, for its four million covered members. Other common examples of educational materials cover unfortunately common conditions like breast cancer and diabetes. These may not be the most relevant to smaller companies with pipelines focused on rare disease products. But keep in mind, rare disease treatment is complex and understanding access and coverage for both rare and common diagnoses is important to both parties. Most important to employers are the costs of their plans. Some are purely driven by price. Others may utilize controls around quality or safety but it is all done in the name of cost-effectiveness.
Also, biopharma involvement goes beyond just funding patient education material.
Each year, the Northeast Business Group on Health (NBGH) publishes a guide to help establish value-based cancer benefits for employer member groups across the U.S. While there’s no mention of specific treatments, the guide emphasizes using evidence-based decision making, integrating care navigation, and closely controlling treatment options as a way to manage costs.
Merck, Biodesix, and BMS/Celgene not only bankrolled NBGH’s paper but sat in on roundtable discussions affecting cancer treatment options. Additionally, the Florida Alliance for Healthcare Value established its Employee Benefits Advocate program, an ongoing service targeting complex chronic conditions like cancer and rare diseases. Several biopharma manufacturers had a hand in financing and developing resources for the program.
It’s easy to see how incentives start to blend together over the interests of quality, safety, or value. Competitive product placement within the lines of therapy is key, but decisions can also be tied to the systemic costs of offering health benefits. When there are few or no other treatment options (as is common with high-cost rare disease treatments), product differentiation becomes less important. Overall, it’s crucial to justify a product’s value on the employer group’s scale or risk being excluded altogether.
4. Leveraging relationships within one coalition may provide opportunities to disseminate specialty drug info to other types of associations or lobbying bodies such as NCCN and COA.
Business health coalitions rarely operate within a vacuum; research, education, and the latest findings are often shared between coalitions creating a valuable web of information. Also, some coalition board members have ties to other employer initiatives with similar missions like the National Comprehensive Cancer Network (NCCN) and Community Oncology Alliance (COA). That means getting in close with one coalition can have a broader impact as information is shared with other like-minded organizations. This could be a worthwhile endeavor for market access teams who may be limited by COVID in the ability to get on site with providers. There’s value in interacting with the actual policy decisions from the HR function of large employers or exposure to the opinions of their trusted advisors.
5. A top-down approach can help biopharma manufacturers get information into the hands of coalitions around the country.
Some business health coalitions take a more hands-off approach and simply apply information passed along from the National Alliance of Healthcare Purchaser Coalitions instead of creating original resources and initiatives. A coalition of coalitions, the National Alliance publishes pharmacy benefit management guidance and case studies at the national level. In regards to cancer resources, the National Alliance is also creating a set of modules for the oncology patient journey, hosting employer roundtables for coalitions, and developing strategies and best practices for dealing with cancer in the workplace.
Navigating the intricate web of business health coalitions both at regional and national levels is no easy task. But these thought leaders are affecting real change in the way health benefits and costs are handled for millions of members around the country. So, do your homework and see what might be a fit for you.
At DKP, we help the industry stay current on the latest rare disease, oncology, and gene-cellular trends that might affect your patient population. Our team scours the latest initiatives from coalitions, legislation, payer policies, and more. If this is something you want to learn more about, we’d be happy to talk with you. Reach out to us today.