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Reimbursement ≠ patient access

By Toby Gunner

Toby Gunner

For many years now, our approach to market access has focused too heavily on budget impact rather than value.

In our experience, creating future- proof reimbursement strategies now relies heavily on achieving two critical components. Firstly, that the way to transform healthcare is to realign competition within the healthcare system and instead focus on value for patients. (Value in the healthcare system = health outcome per pound/euro/dollar of cost expended.) The second component is optimal patient pathways that deliver value for patients through improved outcomes.

It is only through a focus on value across the whole system that high quality, sustainable healthcare systems are achieved. This is a fundamental approach in future reimbursement. It has also been brought into sharp relief recently as drug reimbursement has become easier to achieve, while patient access has become further away from our reach.

Healthcare organisations have long talked about adopting a value approach. Across Europe and the US, value-based procurement is being debated, trialled and implemented. The healthcare sector is clearly moving away from traditional lowest price procurement strategies and product buying, and this has been seen with the new routes to reimbursement available in the UK today.

Increasingly we see companies gaining reimbursement for innovative therapies through the various reimbursement routes and accelerated access channels, only to see limited patient access. In extreme cases we are seeing charities provide bursaries to hospitals to ensure patients receive new therapies. This clearly limits patient access and prohibits equity of access.

Why is this? The simple answer is COVID-19. As an accelerant to the capacity crisis in the NHS, it is unprecedented. The reality is, however, the NHS has been prioritising restructuring to a value-based healthcare system for some time, as the current system became increasingly unsustainable.

The news regularly features the capacity crisis in the NHS. All services are struggling, trying to fulfil unprecedented demand with reduced capacity and additional backlogs. Winter is coming, and the NHS is redeploying finite resources to cope with another wave of unprecedented demand. Already the latest figures are showing the busiest summer ever for the NHS emergency departments. July saw the highest number of category 1 ambulance call-outs since records began. Against this backdrop, normal service delivery is struggling. The net result is both established therapies and new therapies are facing significant barriers to patient access.

Therefore, we believe capacity within the healthcare system is the biggest barrier to market access for our clients. No longer can reimbursement be the primary focus of market access activities. Increasingly, we are discovering that drug reimbursement within specialised commissioning has been decoupled from the commissioning of the necessary service to facilitate treating patients with new therapies. Introducing expensive new therapies into a stretched service or within existing tariffs means it’s not viable for providers to deliver the treatment within traditional models.

It’s said that the greatest danger in times of turbulence is not the turbulence, it is to act with yesterday’s logic. It is certainly a time of turbulence within our healthcare system.

It is also an opportunity to further develop the partnership approach and value that pharmaceutical companies demonstrated to healthcare systems during COVID-19. How do we do this? The simple answer is to demonstrate our commitment to value-based healthcare.

To achieve reimbursement in the future that is representative of patient outcomes, companies will need to continue to robustly map existing pathways, evidence the current costs and outcomes within the pathway and model the costs and outcome of product entry or service innovation to the future pathway. Importantly, working with the healthcare system to develop and evidence innovative new service delivery models and pathways will be critical in achieving patient access. Launch activities will have to include data capture on a product’s performance and patient outcomes to satisfy future reimbursement models that are linked to value in real time.

Thankfully the NHS’ focus on integrated care systems is designed to deliver value- based healthcare. They are, by definition, partnerships of organisations that come together to plan and deliver joined-up health and care services, and to improve the lives of people who live and work in their area.

The road map for market access moving forward is clear. Access in the UK requires a national and sub-national focus. A deep understanding of a therapy’s value within existing or new pathways. This needs to be generated through deep insights into problems within the system and a compelling narrative that positions therapies against the backdrop of value-based healthcare. The healthcare system is clear in how it expects pharmaceuticals to demonstrate value. Pharmaceutical companies are inherently innovative. Supporting innovative new pathways and delivery models within the healthcare system is a key practice of our market access activities.

Toby Gunner is CEO of Nzyme Group

19th October 2022

From: Marketing


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