The Population Situation – The Future of Payer Perspectives

Physicians manage patients, and may ask themselves:
• How can I improve outcomes for my patient John Doe, based on his individual disease?
• How might my approach differ for my other patient Jane Doe, based on her individual disease?
• How can I help my patient by better understanding their insurance benefits and the affordability of their medication?

Payers manage populations, and may ask themselves:
• How can we improve outcomes for a particular disease state across the relevant patient population?
• How can we ensure all of our patients with a particular disease are managed properly (adequate care and appropriate medication)?
• What are the total costs (direct and indirect) for this disease?
• What is this disease costing us per member per month (PMPM)/ per member per year (PMPY)?
• How can we lower PMPM/PMPY while improving outcomes across our population with this disease?

Some large payers with sophisticated infrastructure can answer their own questions – by analyzing their own data and assessing their broad “population situation” within and across multiple disease states. We have seen the big dogs start in areas known as the “low hanging fruit” – diabetes, CHF, COPD, etc., which are also areas where existing quality measures and/or incentives/disincentives are applied. These payers have been able to identify the cost implications that occur when some of these members have uncontrolled or under-managed disease. As such, they have implemented population health programs intended to support improved outcomes – through initiatives including nurse interventions, case management, patient outreach, etc. These programs also support thriving members from falling through the cracks.

As of recently, we have seen the population health approach expand beyond large therapeutic categories, to specialty categories as well – immunology, GI, and others. Payers are starting to realize that broad prevalence isn’t the only criteria that may indicate a certain disease state is a prime candidate for a population health approach. Smaller categories with unmet clinical needs, high direct and indirect costs, etc. are also excellent areas to focus on using that “population lens.” As the demographic of payer memberships change, the focus of population health initiatives also change. Additionally, as serious conditions like RA, HIV and cancer become chronic, it is important for payers to shift their population health approaches to meet the needs of the changing environment. While prevalence in specialty categories may be much lower than say – in diabetes, there are definitely opportunities to improve outcomes and lower costs which, if calculated as PMPM or PMPY, span across the entire member population.

Where is pharma’s “low hanging fruit?” Pharma companies have the unique opportunity to go deeper with payer customers – tap into their data sets, and align with their priorities. We are in a world where transactional engagements and contracts alone won’t differentiate. It is critical for pharma to demonstrate value beyond the drug.

So – pharma – as demographics change and landscapes evolve,
• Are you prepared to support payers in managing their populations?
• Are you well-equipped to support payer customers in mining data and identifying opportunities for population health initiatives?

If pharma and payers can join forces on population health approaches to lower costs and improve outcomes – everyone wins, right?

Author: Jamie Van Iderstine

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