The frustrations that pharma – and clinicians – face when trying to secure a drug on formulary have been well documented. But Omar Ali (pictured) explains that understanding the Payer’s ‘language’ can greatly increase the chances of success.
The NHS changes over the last decade have shifted power away from secondary care to varying degrees in different specialties. These new NHS changes are further exaggerating this. Pharma has a significant role in facilitating consultants in keeping in step with these changes, supporting them through the brave new world, and ensuring that they learn a second language – the language of the Payer.
A very good friend of mine – she is a Consultant Cardiologist – said to me not so long ago: “Omar, I don’t see why I have to justify my prescribing to you. This is the drug I want, just give it to me.” This was a delicate discussion. I needed to handle myself carefully but be firm to the point. There were also two pharma representatives at the table. Basically my reply went something like this: “Dear Dr, regardless of what you feel about justifying your prescribing decisions to me, this is the process, this is the financial framework for the managed entry of new drugs into the health economy – so get with the programme.” I also added that I could help her if she’s interested in how to best go about this. Within the next
three months I was indeed requested to present at a mandatory briefing for all consultants within the Trust on the current financial position and the future of our organisation with the new financial framework for commissioning new products onto formulary – my presentation was sandwiched in between our CEO and the Department of Finance!
So what can pharma do to assist my Consultant Cardiologist colleague to better ‘frame’ her positional argument to me? There are five key factors to consider:
1. Understand the Health Bill and commissioning: secondary care is somewhat hidden from much of these changes. Pharma needs to pull these influential clinicians out of their comfort zones and brief them on the changing NHS.
2. Understanding the Drug and Therapeutic (D&T) processes/ APC Formularies: many clinicians are frustrated with the system, do not understand and speak the ‘Payer language’ and so disengage from the process as a result. Pharma needs to bring them back to the table and empower them in a new way.
3. How to get a drug ‘through the D&T’: – it’s a simple workshop and a skill that can be learned with clinical and geo-political factors brought in. Use your brand as a ‘case example’, but the principles are the same. Many consultants will echo the discussion I had
with my consultant – frustration at the barriers to access, pointing accusingly at cost savings, and not prepared for the Payer’s rigorous Q&A. In a way, these KOLs need to be briefed in a secure environment as to what they may face when in front of the firing line
of the PCT/D&T Committee.
4. What makes a good D&T Application: streams of new drugs fail at the first hurdle. Quality of submissions are often poor and do not resonate with the Payer’s audience. They still resound of “I’m professor of cardiology, if I bang my fist on the table I will get my drug funded”. You have a role, duty and responsibility in assisting one of your most valuable
support mechanisms. Without KOL support the Payer’s influence is actually irrelevant.
5. Understand the difference between ‘being on formulary’ and ‘commissioning a new drug
into a pathway’: most consultants don’t fully understand how their own activity is reimbursed; issues around expensive drugs, tariffs for admissions/outpatients – and related trim-points – and implications of red/amber/green prescribing guidance. The subsequent generation of a shared care guidance is critical for your brand. Without this will mean a lack of prescribing which results in a reduction of sales.
We currently have at least eight new brands which have passed D&T application, have passed PCT APC, and are on formulary; but do NOT have a shared care guidance in place. This means they are in ‘limbo’. They are in ‘hyper-space’. A consultant simply won’t be able to prescribe it. The GP won’t be able to continue. This is about joint working, bringing
stakeholders around the table, bringing examples of best practice from around the country, and bringing your agenda so that it becomes higher on my own.
The KOL ‘demand’ factor
It’s one thing for a Payer having to deal with a well prepared consultant who understands the financial process and has made a convincing positional QIPP framework for your brand. It’s quite another when the KOL has not even turned up and has disengaged from the application and support process. That speaks volumes to the Payer. Please don’t confuse ‘KOL demand’ for a treatment option with a ‘KOL demanding a brand’.
Payers look for and make a judgement on ‘KOL demand’ for a product. It is critical when deciding on an initial interest level. Remember that Payers are often ‘fighting off’ consultants from various disciplines and specialties wanting new products. The silence from KOLs with reference to your brand can be deafening in what it spells out: “this product holds no value to us”. Make sure they are knocking on my door with ‘demand’. Now once we have engaged, what I don’t want is your KOL simply ‘demanding the product’. What I want now is a financial QIPP framework focusing on how we redesign our services around a new intervention, in both clinical and commissioning terms.
What disappoints me is that the majority of D&T support to consultant KOLs I see today from pharma falls under two main themes:
1. Pharma translates ‘the need for evidence’ into dumping ream after ream of largely irrelevant clinical papers onto the desk of the consultant – which further makes them want to disengage.
2. Pharma translates ‘the need for a better quality application’ into taking the D&T form
and having their medical departments complete them on the behalf of the consultant.
Trust me, when these come to D&T you can see them a mile away!
Given pharma is always touting joint working why don’t you work together on this issue? Coordinate your timetable of formulary applications, enrol your KOLs into a D&T workshop where they receive some skills set training and ‘mock D&T’, and empower them in the ways of the new NHS. And have your executive teams keep them abreast of local payer
influencers and mechanisms with underlying framework for prescribing pathways.
Falling in love
Some of you will know I’m currently in the process of moving house. We have just gone in to the market and indeed have fallen in love with a house in Guildford. Now here’s the thing. We fell in love with the house when we first saw it and this continued throughout
our viewing. We have pictured it becoming our home, almost living out the years. The garden is perfect, the rooms all fit with what we want and, although it’s not quite the ‘moon’, it sure as hell is a good way towards it.
Now, to get into the house – our new home – we need to go and see the bank. It wasn’t a great first meeting, I can tell you. All of a sudden we found ourselves wrestling with APRs,
2yr/3yr/5yr fixed plans, repayment versus interest only, deposit amounts, indicative financial re-payments and limitations on loan to value thresholds that have unsettled us somewhat. We came out of that meeting a little dizzy, somewhat dejected and unsure now of what and where we want to go. We still don’t relish the idea of going back. We won’t say it out loud, but we are slowly losing this house.
The discussion at the bank was a far cry from the romantic notion of what was to be our home. The bank was not really interested in the lovely garden, wonderful residential location and how we could see our children growing up in the various rooms within the property. No, it seems the meeting with the bank revolved around a very different language. It was a financial framework. It was a requirement we have to prepare for adequately to get us into our next home. I now know we could have been better prepared
and that poor preparation may have cost us our ‘moon’. I learned that I had to get with the programme, regardless of my views of bankers’ bonuses, financial hurdles and an annoyance at justifying our income/expenses to a third party.
There is no way I will get into my dream home without getting to grips with the financial framework that is required to proceed the dream into reality. Many of your KOL consultants have already done the first part. They see the USP of your product, the
clinical need is palpable, they have patients waiting to reap the benefits of your drug. In essence they’ve fallen in love with the brand. But here’s the thing, are they prepared for meeting with the bank? Are they prepared to entangle with the financial framework
to get them their gold standard product? Or are they in danger of losing their dream home because they have not got with the financial framework?
Think about it.
Omar Ali is the Formulary Development Pharmacist for Surrey & Sussex Health NHS Trust and sits on the External Reference Group for Cost Impact Modelling for NICE.He may be reached on email@example.com.