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Quality of Coverage: Getting the Answers You Need

Quality of Coverage: Getting the Answers You Need

I want you to picture your favorite book. Maybe it’s a weathered sci-fi paperback, a shiny personal growth resource, or the latest true crime novel. (I’ll be the first to admit I’m currently nerding out on The Witcher book series.)

Now I want you to imagine getting that book for the first time with a bunch of pages randomly missing. Not only would this be super frustrating, but it certainly wouldn’t be very helpful. It would be hard to follow what was really happening. And with so many details left out, the big picture wouldn’t be clear at all.

This lack of clarity comes into play when it comes to payer business intelligence, too. Many market access consultants rely heavily on artificial intelligence scraping the web for coverage and access statistics. They hand raw data over to clients and call it a day. This approach not only leaves manufacturers feeling confused, but can also be dangerously misleading.

It’s nearly impossible to make sound, strategic decisions when you’re only being told part of the story.

To gain a full understanding of a product’s coverage and reimbursement, it’s important to really look at the quality of coverage. For us at DKP, that means going deep and wide in our work by scouring payer language and nuances, cross-referencing sources, interviewing key advisors, drawing on years of industry experience, and applying people-powered interpretation to everything we do.

If we really care about getting life-saving treatments into the hands of patients who need them, then we can’t settle for good enough. It’s not good enough to just look at incomplete formulary data. It’s not good enough to make assumptions. It’s not good enough to just report on the number of payer policies and call it a day.

We have to look deeper to truly understand the implications of how well a payer is covering a product and how that will ultimately affect the patients needing access.

Patients deserve better.

And that is why we do what we do here at DKP. That’s why we take such a comprehensive approach when it comes to determining quality of coverage.

We set out to uncover answers to questions like:

  • What access barriers might a patient encounter?
  • What types of provider documentation are required for coverage?
  • How well does a payer’s language match up with FDA labeling?
  • What other sources are payers referencing beyond the label?
  • Are payers citing the most updated and relevant info?
  • Are payers incorporating clinical trial inclusion/exclusion criteria in policy language?
  • What’s really happening in the marketplace around this product or class of drugs?

Going all-in on determining quality of coverage means coming back with meaningful data and actionable insights. As a result, our clients can move forward with confidence, knowing they can swiftly go after the real issues at hand. Because when it comes to market access, especially in the areas of rare disease, oncology and gene/cellular therapies, having the whole story makes all the difference.

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