For years, market access teams within the biopharmaceutical industry have relied on regional, state and national medical and pharmacy covered lives data to size and scale their markets, identify targets, and set priorities for their strategy and contract negotiations.

But there are major gaps and shortcomings with use of this patient data for many new, emerging and existing therapies.

It’s time to reevaluate the use of covered lives data.

Limitations

Covered lives data force some assumptions. Does every account contain an equal proportion of patients with need for a particular therapy? There may be significant variance in socioeconomic factors, demographics, disease etiology and geography influencing patients and treatment.

More specifically, covered lives data may ignore the impact of disease on patient earnings, working potential, and overall insurance plan. It is critical when setting market access priorities to understand not only covered lives, but the lives of those clinically addressable within a particular account.

Recognize Clinically Addressable/Eligible Patients

Consider the patient working for a large employer who is diagnosed with a chronic illness and is no longer able to work. This will change his or her access to treatment.

When you consider the clinically addressable market, accounts previously dismissed as too small or too regional may be hidden gems with even greater priorities and targets. There may be many patients relative to a larger account, but fewer who are clinically eligible.

Rates and Contract Negotiations

It is important to know who you should target when handling contract negotiations with payers for rebates and reimbursement.

Are you settling for higher reimbursement to a particular payer, when the actual addressable market within that account is much lower than would make that rebate amount worthwhile?

Are you providing larger rebates for commercial patients when many clinically eligible patients within that account are covered by a Medicare formulary?

STATinMED RWD Insights

We provide comprehensive data insights across the business landscape that are comparable in capture:

Payer Type Total Patient Counts – RWD Insights Percentage of Nationally Insured per KFF
Commercial 153.4 MM 87%
Medicare 64.1 MM 90%
Medicaid 43.9 MM 70%
Government/Other 17.2 MM NA
Total 278.7 MM 87%

KFF: Kaiser Family Foundation; RWD: real-world data

Representative Capture of Insured Population By State

Clinically eligible lives data powered by STATinMED RWD Insights offer accurate and timely TRUE market opportunity, where detailed utilization management policies are managed, and contracts are negotiated.

Get healthcare claims data by payer account and channel level (e.g. Aetna Medicare Advantage), and by geography (e.g. census region and state) with no estimation factor or protection involved–these are true lives.

Early market access planning teams can also leverage STATinMED RWD Insights for patients who have failed a previous therapy or those who must fit a specific diagnostic and/or demographic profile (must have specific disease and 18 years of age or older).

Representative Capture of Insured Population By State

RWD Examples: Varying payer distributions vs national average assumption

According to the Kaiser Family Foundation (KFF), the national distribution of insured lives across the country is as follows:

With so much variation between national coverage and coverage within a particular disease population, the account level variation also differs—further emphasizing the importance of going beyond covered lives to clinically addressable lives.

COPD: chronic obstructive pulmonary disease

55% of patients are commercially insured in the United States, however when you consider patients with COPD, 60% are enrolled in Medicare and only 25% have commercial coverage.

Value of Access Strategy with Clinically Eligible Lives Data

  • Set realistic expectations on uptake within an account
  • Realize competitive contracting opportunities with target payers
  • Prioritizing accounts based on gaps in competitor activity
  • Optimize and support evidence planning
  • Identify value-based contracting opportunities

Realize maximum value through our data, insights and solutions.

Our proven data advisory approach and RWD Insights go further, delivering market access data that makes a difference for you and for patients.

Contact STATinMED Research today to schedule a complimentary needs assessment!

We understand real-world evidence and solve problems with confidence. Contact STATinMED’s Strategic Advisory Services to learn more! 

As real-world evidence authorities, STATinMED Research discovers data, develops insights and delivers optimal solutions to help life science companies realize maximum value.