Optimizing Rebates at the Payor-Plan Level
Background
- Leading SGLT2 brand experiencing profitability decline
- High payor rebates negotiated to maximize access to T2D patient lives not translating into lower reversals/ rejections or higher patient share across all plans
- Variations in rebate data formats make holistic analysis challenging; data quality issues add to the complexity
- KBQs: Why did higher rebates not translate into higher patient share? What actions are needed to improve brand profitability?
Objective
Perform payor-plan level analysis incorporating disease-severity level for T2D patients, and recommend specific actions to optimize rebates at the payer-plan level- Determine % of covered patients initiating therapy, and experiencing reversals/rejections at the payor-plan level
- Stratify patients into H/M/L disease severity levels
- Stratify plans into H/M/L segments based on the number of patients with H/M disease severity
- Project profitability of H/M/L plans and recommend actions to improve brand profitability
Approach
Leveraged rebate, adjudication, APLD and formulary data to recommend payor-plan level rebate optimization:- Ingested payor data and create an integrated payor-plan rebate database
- Analyzed adjudication, APLD claims and formulary data to determine patients initiating therapy vs. those experiencing reversals and rejections at the payor-plan level
- Stratified patients into H/M/L disease severity segments; Stratified plans into H/M/L segments based on H/M severity patients
- Evaluated ROI for H/M/L plans, especially those associated with payors receiving substantial rebates
- Developed recommendations to optimize payor rebates by maximizing access to H/M disease severity lives within plans
Insights & Results
- Not all plans are made equal - # of covered lives does not always equate to # of patients on therapy
- 8% rebate reduction for major PBMs while maximizing access to their H/M disease severity patients most likely to initiate/stay on T2D therapy
- 6% higher approval rate for CVS, OptumRx and ESI patient claims
- 4% increase in brand profitability