Outcomes Based, Innovative Contracting (OBIC) Ali_pres_OBIC Process... · Outcomes Based,...
Transcript of Outcomes Based, Innovative Contracting (OBIC) Ali_pres_OBIC Process... · Outcomes Based,...
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[email protected] – Cell +447939556001
• Omar Ali
Outcomes Based, Innovative Contracting (OBIC)
Examples, Key Learnings & Development Process
[email protected] – Cell +447961317806
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Introduction
o Omar Ali - NICE 9 years & former payer for NHS Surrey & Sussex
- PhD in risk share & innovative outcomes based contracting
o Nick Merryfield - Managing Partner, Stisali Limited
- Omar’s assistant for the workshop
o Stisali, highly specialized OBIC practice:
• Create & deploy Global, U.S. & EMM OBICs
• Est. by payers from mature managed markets - personal experience in OBICs
• Jointly engineered The Advanced OBIC Development process - PhD
• Significant aspect is payer psychology
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“When you eliminate the impossible,
whatever remains, however improbable,
is possible”
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Workshop objectives
Practical not theoretical
The Why, When, Who, What & How of OBIC construction?
Approach:
o Real-life OBIC case studies from mature managed markets
o What worked, what didn’t & why?
o U.S. OBIC development process overview & get your hands dirty time
o Group discussion
1 word on Brexit
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The Why, When & Who of OBICs?
Why? - Offensive
o New to a busy market
o No major differentiator
o Reinvigorate poor sales
o Eliminate competition
Why? - Defensive
o Competition arriving
o ICER too high
o No access
o Counter competitor OBIC
When?:
o Reactive
o Pro-active
o One in the pocket
Who?:
o Commercial
o IDNs
o Plans
o PBMs
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What works, what doesn’t & why?
Case studies
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Case study 1 – Pazopanib - UK
Drivers:
o Late to market
o Other drugs rejected by NICE
o Head-to-head trial data 2 yrs out
o Need to do something different
Scheme:
o 2 part scheme:
o Stage 1 = simple 12.5% discount to match incumbent
o Stage 2 = discount based on clinical trial data in 2 years time
o If positive, Payer pays list price
o If inferior, Payer receives rebate on all patients plus future discount
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Case study 1 – Pazopanib - UK
Barriers:
o Payer would reject without head-to-head trial
data - needed data
o How to track supply through homecare?
o Contracts not to breach legislation
o How to track patients over time of H-t-H trial?
Attributes:
o Ability to sell drug now, based on future trial data
o Simple scheme to monitor outcomes
o NICE arbitrated on success of clinical trial
o Payer driven contract
o Easy ability to contractually scale
o Additional discount was in confidence
o No "bank" interest charged
o Few patients / high cost drug
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Did it work?
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Case study 2 – Avastin varied neoplasms - Germany
Drivers:
o Financial constraints
o Perceived unclear efficacy for Avastin in certain neoplasms
o Avastin’s high price
Scheme:
o Manufacturer pay back cost of drug if cancer progressed in 3-5 months
o If >10g Avastin prescribed in 12 months, manufacturer pays for additional cost over 10g
o Money back to hospital not payer
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Case study 2 – Avastin varied neoplasms - Germany
Barriers:
o Payers were circumnavigated
o Largest payer called the contract unlawful
o Negative press release from Drug Commission
of the German Medical Association
o Data protection issues raised on patient record
systems
o Many hospitals reluctant as legal nature of
contract unclear
Attributes:
o Manufacturer generated a legal decision that
hospitals can claim special rebates
o Manufacturer held a press conference
o Payer promised an evaluation of the contract at
period of time in the future - never happened
o Manufacturer designed which patient groups to
include
o Manufacturer designed what success looked like
o Form contract agreed via third party, paid for by
manufacturer
o No maximum cap on patient numbers
o Pharma drove this scheme and the payer did not
change it
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Did it work?
Payer circumnavigated
Pharma. led 100%
PR disaster
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Case study 3 – Cimzia - UK
Drivers:
o 5th RA market
o No clinical or cost advantage
o No physician brand/class loyalty
o Biologics reserved for late in clinical pathway
o Limited clinical indications - RA
Scheme:
o 1st 3 months of prescribing free
o On 4th dose payments starts - indicates treatment is working
o To incentivize physicians to use Cimzia, Payers allowed use of Cimzia earlier in the patient pathway
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Case study 3 – Cimzia - England
Barriers:
o Physicians did not want to switch to new meds
o How to track supply through homecare
o Clinical pathway & formulary required changing
o Uncertainty on manufacturer continuing scheme
o Payers could not push change on Drs
o Difficult disease to measure success
o Company did not know Drs
o Low company sales resource
Attributes:
o Simple scheme to monitor outcomes
o Payers defined what positive response looked like
o True risk share
o NNT = 1
o Pre-authorization via clinical software but simple
o NICE did BIM on extra cost v savings
o Payer sold scheme to other payers
o Drs could pull out at anytime
o Payer checked & changed contract
o Easy ability to contractually scale
o Quite a loose contract compared to others
o Didn't mandate Drs use the drug - used incentive
o Clinical pathway changed
o Few patients / high cost drug
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Did it work?
Strong physician& patient narrative
Increased access
Payer driven – P2P sales
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The Advanced OBIC Development Process
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The Advanced OBIC Development process
OBIC – Innovative, outcomes based contracting; Orange = after main development, internal
OBIC
development:
X2 fully developed contract themes per indicationcontracts per indication
Key legal & reg
Science hits the math
8-12 weeks 12 weeks 12 weeks
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Research & analysis
4
PROVIDER POSITION
PHARMA NEEDS
PATIENT JOURNEY
PAYER PYSCHOLOGY
By Drug, Indication,
CompetitionRegion or
Local Market
CultureLocal regulatory
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Hands on time – Concept Modelling Phase
Scenario:
o Want to get you involved in a small part of the process to develop an OBIC
o Developed a fictitious work through
Exercise:
o In pairs or as a table review Worksheet 1
o List of example key drivers distilled from research phase relevant to fictitious oncology therapy area
o Our Payers have placed their importance on each driver
o You must now place your importance on each driver i.e. how important is this driver in an OBIC to you?
o To help, a standard industry response is in the left column – simply mark your differences
o 5 mins
o Go round the room to see where differences are
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Concept modelling – mapping drivers & hooks
5
Example characteristics, drivers and hooks derived from the research & analysis process; each with relative importance to payer & pharma.
Payer & provider psychology for drug, indication, class & local market established.
Key:
= High importance
= Variable importance
= Low importance
TBC = Presently unknown value, to be confirmed
EXAMPLE OBIC CHARACTERISTICS, DRIVERS & HOOKSLEVEL OF IMPORTANCE
TOPHARMA
CLIENT PAYER
General:
Administration Simple & easycontract set up
Low cost
Driver TBC
Driver TBC
Driver TBC
Clinical Improved clinical outcomes
Driver TBC
Persistence/AdherencePatient adherence improved
Driver
AccessFormulary exclusivity for suitable indications
Driver TBC
Driver TBC
Driver TBC
Driver TBC
FinancialProvides a competitive financial discount
Total cost of care reduced
Driver TBC
Financial risk taken by both other party
Driver TBC
Driver TBC
Driver TBC
Driver TBC
Driver TBC
Other:Driver TBC
Driver TBC
Driver TBC
Driver TBC
Drug & Therapy
Specific:
Outcome measuresOverall Survival (OS)
Driver TBC
Driver TBC
Driver TBC
Maintenance Not to impact a patient’s QOL
Driver TBC
TestingUniversal bimarker testing
Driver TBC
DurationDoesn’t drain funds at end of life
Other Increases payer education on total utilization cost of disease
Driver TBC
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Concept modelling
structure
Common Value ExamplesSimple contract; Low admin costs; Common Value #2, Common Value #3, etc.
Smaller household quarrels (negotiation variables)
• Payer guarantees adherence• Gain formulary exclusivity• Improved Tier position• Negotiable 4• Negotiable 5• Etc.
ACHIEVE OBIC BENEFITS FOR BOTH PARTIES
Pharm
a C
SI E
xam
ple
s
Paye
r CSI E
xam
ple
s
CSIs =
Critica
l Succe
ss Impera
tives
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How OBIC levers & the narrative tie into the
Brand
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Concept modelling - OBIC levers
7
Creation of six to ten potential OBIC levers to:
1. homogenize common areas
2. bridge major CSI differences
3. provide a platform to negotiate variables
Narrative creation included at this stage
For illustrative purpose only – example of a simple OBIC lever
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OBIC development overview
Access for X at fixed YFor indication yWith Z number of coursesFor Q outcomes guaranteed
Access for patients in XOutcomes – guarantee forRebate for Z
Product X OBIC Contract 1 Title
Product X OBIC Contract 2 Title 2
1
8
Contract Objectives Summary
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The Advanced OBIC Development process
OBIC – Innovative, outcomes based contracting; Orange = after main development, internal
OBIC
development:
X2 fully developed contract themes per indicationcontracts per indication
Key legal & reg
Science hits the math
8-12 weeks 12 weeks 12 weeks
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Group discussion
Question – show of hands:
1. Reactive
2. Pro-active
3. Prepare one for the pocket now?
4. Do nothing?
Thoughts on taking the journey?
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Workshop objectives
Address the practical Why, When, Who, What & How of OBIC construction?
Approach:
o Real-life OBIC case studies from mature managed markets
o What worked, what didn’t & why?
o OBIC development process showcase & practical application
o Group discussion
1 word on Brexit