Blog
Throwing Shade on Exclusions is Like Throwing Stones in Glass Houses
The modern proverb “people who live in glass houses shouldn’t throw stones” originated in 1385 when a primitive version…
December 9, 2024-
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BlogWhy Payers and Hospitals Don’t View Hospital-at-Home Programs as a Home Run
In The Wizard of Oz, when Dorothy is ready to return home to Kansas, Glinda, the good witch, gives…
November 13, 2024 -
BlogSanding Off the Edges of the FTC’s Complaint Against PBMs
When sanding wood, different grits are used for different purposes: extra-coarse grits to smooth extra-rough and uneven surfaces and…
October 15, 2024 -
BlogAn Iconoclastic View of Price Negotiations and Restrictions
For millennia, people have looked at the heavens and tried to make sense of what they saw. Several moments…
September 18, 2024 -
BlogDying For Payers to Improve End-of-Life Care
There’s life and there’s death. It’s dichotomous… sort of. Dying is a process toward the end of life, and…
August 14, 2024 -
BlogAn Axe to Grind — Biased Pharma Analyses and Reports
The idiom “to have an axe to grind” means to have a selfish reason or strong opinion that shapes…
July 17, 2024 -
BlogSome Payers are Hungry to Help Members Eat Better
You are what you eat. There is no denying the importance of good nutrition. A healthy diet can lower…
June 12, 2024 -
BlogWorking Out the SMARTs of Setting Premium Goals
Sometimes we meet or even exceed our goals, and sometimes we fall short. For example, we might set out…
May 15, 2024 -
BlogMaybe the 340B Drug Pricing Program Costs Employers $3.40B
We’re constantly making predictions. Will it rain? How will they respond if we do or say X? How much…
April 9, 2024 -
BlogPrescription Drug Importation Gradients and Barriers
We’re surrounded by countless currents carrying things from one location to another. Temperature gradients, concentration gradients, pressure gradients, electrical…
March 13, 2024 -
BlogWhen Payers Trash “Wasteful” Products Through Formulary Exclusions
Why purge physical items when we can just rent additional storage space? Why delete digital files when we can…
February 14, 2024 -
BlogIn Defense of Step Therapy, Step by Step
If you’ve been in an old European castle with spiral stairs, then chances are the spiral stairs had a…
January 10, 2024 -
BlogIRA Risks and Manufacturers’ False Sense of Security
Do you remember watching Steven Spielberg’s 1975 movie Jaws? If so, you likely recall an early scene at a…
December 13, 2023 -
BlogFrowning on How Payers Discount the Value of Healthy Smiles
Smiling has been shown to boost mood; reduce blood pressure, pain, and stress; increase endurance; and strengthen the immune…
November 15, 2023 -
BlogThe 6-minute Walk Test — a Cheap Test With Costly Consequences for Payers
Let’s suppose you’re motivated to work on one of the several global challenges we face (God bless you). And…
October 12, 2023 -
BlogWeighing In on How Payers Cover and May Cover Weight-loss Drugs
Demand for products that combined “fen” (fenfluramine), an appetite depressant, with “phen” (phentermine), an amphetamine, soared after a small…
September 13, 2023 -
BlogAre Payers Listening to Evidence on Hearing Aids?
Most of us likely have heard the Verizon Wireless character say, “can you hear me now?” Those commercials ran…
August 16, 2023 -
BlogAI-supported Access Decisions May Not Reflect Our Values
As artificial intelligence (AI) permeates all facets of work and life, many thought leaders are increasingly concerned that AI…
July 12, 2023 -
BlogWhen Payers Pay for Sexual and Reproductive Health Services
Some find open conversations about sexual and reproductive health uncomfortable, yet many federal and state politicians comfortably and publicly…
June 14, 2023 -
BlogWhen Payers Are Forced to Cover Treatments Lacking Evidence
A 1992 commercial starts with a young student coloring as the teacher drones on: “Stay within the lines, the…
May 18, 2023 -
BlogUnpacking Lilly’s Weighty Announcement To Cap Insulin Out-of-Pocket Costs
“What’s in your backpack?” is a reference to the psychological load one carries. People with diabetes carry a heavy…
April 11, 2023 -
BlogFloating the Possibility of National Insurance for Gene Therapies
Travelers Insurance Co. has used an image of a red umbrella in its logo since 1870. It’s brilliant imagery…
March 15, 2023 -
BlogWhipping Up Some Thoughts on Member Churn
Churning converts cream to butter. This process agitates the cream and separates it into butter and buttermilk. Whereas cream…
February 14, 2023 -
BlogEvidence-based Guidelines and Payers’ Misadventures
Whales sometimes beach themselves, but because of insufficient evidence, we don’t know why. There are several plausible explanations for…
January 17, 2023 -
Blog3.5 Ways Payers Won’t Pay $3.5M for Hemgenix
Probability is the likelihood of something happening. When flipping a “fair” coin (i.e., one that has an equal chance…
December 14, 2022 -
BlogCelebrating Broad Contraception Coverage May Breed Complacency
Harvard Business School Professor of Leadership John Kotter says accelerating change often requires creating and sustaining a sense of…
November 16, 2022 -
BlogWhy Payers Won’t Use a Microscope to See the Benefit of Lecanemab
Optical microscopes — sometimes called light microscopes — use a range of objective lenses to view small objects. Objective…
October 12, 2022 -
BlogPicking the Lock that Prevented Medicare from Negotiating Drug Prices
Picking a lock requires a couple tools, time and effort. In essence, pins are pushed out of the way…
September 14, 2022 -
BlogRules for Payers’ Cost-sharing Exceptions
There are rules, exceptions to rules, and rules for exceptions to rules. Yep, payers have all of the above,…
August 17, 2022 -
BlogWhen Payers Raise the Bar with Prior Authorization Criteria — and When They Don’t
You’ve probably heard the phrase “raise the bar.” While its origin is based on the high jump and pole…
July 13, 2022 -
BlogReflecting on Manufacturers’ and Payers’ Mission and Professional Self-image
When you look in a mirror, who do you see? Not what, but who? How you see yourself may…
June 14, 2022 -
BlogAccumulators and Maximizers Increase Tensions Between Payers and Manufacturers
As far back as the 13th century, European craft guilds set and maintained standards for the quality of goods…
May 18, 2022 -
BlogAccess and Taxes — Tax Policy and Market Access Cannot Be Split
“Chop your own wood and it will warm you twice” is often attributed to Henry Ford, who had the…
April 13, 2022 -
BlogWill Payers Cover U.S. Citizens Injured in the Ukraine War?
War kills, injures, and sickens combatants and noncombatants, including innocent civilians. The horrors of war include burns, broken bones,…
March 16, 2022 -
BlogConsumers Struggle With the Plan Selection Puzzle
For many people, selecting an ice cream flavor — even when there are many to choose from — is…
February 9, 2022 -
BlogEquity and Efficiency, The Cost-Sharing Tradeoff
In his classic 1975 book titled Equality and Efficiency: The Big Tradeoff, economist Art Okun noted the tensions between…
January 12, 2022 -
BlogEstimating Patient Cost Sharing Accurately Is Increasingly Difficult (and Important)
Perhaps you’re familiar with — and sometimes can relate to — the Greek myth of Sisyphus, who is repeatedly…
December 15, 2021 -
BlogClearing the Air on Payers and Smoking
Every year in the United States, diseases linked to smoking kill approximately 480,000 people, including more that 41,000 deaths…
November 10, 2021 -
BlogA Dozen Gene Therapy Uncertainties That Keep Payers up at Night
Out with the old, in with the new. Gene therapies are ushering in a new age of treating and…
October 13, 2021 -
BlogConfidential Contracting — Payers See No Evil, Hear No Evil, Speak No Evil
The three “wise monkeys” depicted in a 17th century wood carving at the Tosho-gu shrine in Nikko, Japan, represent…
September 15, 2021 -
BlogPayers’ Costs Rise as the Earth Warms
The earth is warming — and it is warming faster. For the contiguous United States, the five warmest years…
August 11, 2021 -
BlogHealth Systems’ Prediction Models Following Epic Fall
Humpty Dumpty fell off a wall, and all the king’s horses and men couldn’t put him back together again.…
July 14, 2021 -
BlogWhen Payers Reject What the FDA Approves
There are serious health conditions in which a new solution could fill a big unmet need. In that context,…
June 16, 2021 -
BlogThe Skinny on Payers and Obesity
One might ask: How do I look in these jeans? That’s debatable. The fact that the prevalence of obesity…
May 12, 2021 -
BlogWhen Manufacturers Talk, Do Payers Listen?
If you watched TV during the ’70s, you likely saw various iterations of an ad that said, “When E.F…
April 14, 2021 -
BlogThe Art of Segmenting Payers, Hospitals, and Health Systems
The impressionist painter Claude Monet explored the effects of light on the color of objects. He often painted the…
March 17, 2021 -
BlogPayers Already See Potential COVID-19 Silver Linings
Looking back, social scientists have seen the silver linings of the influenza epidemic of 1918, the cholera epidemic of…
February 10, 2021 -
BlogThe Parallels Between Access Decision Making and 3D Printing
3D printing, or additive manufacturing, creates three-dimensional objects from digital models by adding material, typically layer by layer. By…
January 14, 2021 -
BlogWhen Health Insurers Can’t Predict the Future
Crystal balls have been associated with fortune telling for several hundred years. Today, actuaries do not use crystal balls…
December 16, 2020 -
BlogHow Payers Confront Racial and Ethnic Disparities
The Statue of Liberty has welcomed generations of immigrants to the United States — its torch a symbol of…
November 18, 2020 -
BlogUnmasking Payers’ Not Paying for Face Masks
Superheroes like Batman, Spiderman, Captain America, and Black Panther wear masks, and their brave acts reduce social costs. When…
October 15, 2020 -
BlogPayers’ Trust in Blockchain Does Not Buy Payer Cooperation
The official motto of the United States of America can be found on our currency and coins: “In God…
September 16, 2020 -
BlogAbortion Services: When States Determine Access to Care
Way back, surveyors chiseled marks in stone structures to serve as a “bench” for a leveling rod, ensuring consistent…
August 12, 2020 -
BlogTaking Aim at Payers and Gun Violence Prevention
Everyone negatively impacted by gun violence hopes it is the shot heard around the world. Yet in the United…
July 15, 2020 -
BlogThe Bets Payers Make
Perhaps you’ve noticed that a standard deck of playing cards has 52 cards, just as there are 52 weeks…
June 18, 2020 -
BlogPayers and Hospitals Always Paint by Number
Paint-by-number kits assign colors to specific areas to reproduce art, including great works like Leonardo da Vinci’s The Last…
May 13, 2020 -
BlogPayers’ Response to COVID-19
In these dark and uncertain times, we seek light and predictability — even if that means a new normal.…
April 15, 2020 -
BlogThe Closing of the American Formulary
Someone once said something like, “When one door closes, another opens; but we often look so long and so…
March 11, 2020 -
BlogThe Brands Payers Love
Do you believe in love at first sight — like the instant head-over-heels connection between Cinderella and Prince Charming…
February 12, 2020 -
BlogBusting the Myth That PBMs Are Addicted to Rebates
Sometimes you have to take a step back to see the big picture — the forest for the trees.…
January 16, 2020 -
BlogUnpacking Payers’ Reception of Bundled Contracts
During the holiday season when gifts are often exchanged, one might recall the old proverb: Don’t look a gift…
December 12, 2019 -
BlogHow Price Protection Pumps the Brakes on Drug Price Inflation
If you’ve experienced the joy of attending the Macy’s Thanksgiving Day Parade, you know that the balloons are huge.…
November 13, 2019 -
BlogCutting Through Health Economics and Outcomes Research Hacks
Life hacks are those simple, clever methods that boost productivity or efficiency. While the term life hack was coined…
October 15, 2019 -
BlogWSJ’s Comparison of Drugs to Soda Falls Flat
Cherry Coke is sweet, but cherry picking a comparator to maximize the contrast effect can leave a sour taste…
September 19, 2019 -
BlogWho Owns Population Health – Government, Employers, Payers, or Hospitals?
Population health is on fire and, importantly, makes sense. And though the term is somewhat new (popularized by the…
August 14, 2019 -
BlogWhy a “Favored-nation” Clause Meant to Lower Drug Prices Won’t Work
A level playing field helps to ensure a fair contest between two teams — it wouldn’t be fair if…
July 10, 2019 -
BlogWhen the ACO Fever Breaks
Fads, crazes, hits, and styles come and go. Looking back, the popular diet, toy, song, or haircut now seems…
June 12, 2019 -
BlogWhat Payers Can Get Away With
Why pay taxes? Likely to avoid the potential consequences of tax evasion. Why slow down after spotting a police…
May 15, 2019 -
BlogPayers’ Irregular Views on Standard of Care
Imagine a world without standards. There would be disagreements about everything. There would be no shared understanding of time…
April 10, 2019 -
BlogPayers’ Exceptions That Prove the Rule
You’re probably familiar with the mnemonic “I before E, except after C” which couples both a spelling rule and…
March 13, 2019 -
BlogThe Bottom Line on How Payers Prefer Lower Costs
Many policymakers think there is a drug rebate crisis, and consultants who should know better have led them astray…
February 13, 2019 -
BlogIf ICER leads, will payers follow?
Sherpa guides have led explorers through the Himalayas for many years. In such challenging conditions, an effective guide is…
January 17, 2019 -
BlogHopes and Fears of a Single-Payer’s Monopolistic Powers
Winning a game of Monopoly — assuming players have the stamina to play to the end — depends on…
December 13, 2018 -
BlogFitting Thoughts on Payer–PBM Integrations
Invariably, you’ve questioned the fit of two or more things in countless situations — when working on a puzzle,…
November 14, 2018 -
Blog5 Ways Payers Pay For Innovation
The light bulb has become a symbol of innovation for good reason. Thomas Edison, the inventor and a cofounder…
October 16, 2018 -
BlogDiscounting Problems with Rebates
Criticism of rebates between sellers and buyers is not new. For example, Standard Oil received rebates from railroads beginning…
September 12, 2018 -
BlogCutting Out Talk of Disintermediating PBMs
There is growing scrutiny about the spend and trend of prescription drugs and the role PBMs play in it.…
August 15, 2018 -
BlogPlaying Scrabble as a Metaphor for Selecting Analogs
Life and work are full of decisions — many small decisions and a few big decisions. One of the…
July 19, 2018 -
BlogPayers’ Common Problems with Rare Conditions
The near-monopolistic control the De Beers corporation exercises is the primary reason diamonds cost so much. Diamonds are not…
June 14, 2018 -
BlogWhy Payers Absolutely Prefer Absolute Measures of Risk Reduction
Benjamin Franklin said nothing in this world except death and taxes is certain. Of course, there are other some other…
May 17, 2018 -
BlogTime to Revisit Payers’ Views on Long-Term Outcomes
You know the old saying, “An apple a day keeps the doctor away”? Or how about the idiom “An…
April 12, 2018 -
BlogThree Common Pricing Research Mistakes
The Magilla Gorilla Show’s theme song chanted that “at any price, a gorilla like Magilla is mighty nice.” And MasterCard’s “Priceless”…
March 14, 2018 -
BlogWhy US Payers Often Want to Excise Ex-US Data
The spiritual “Dem Dry Bones” with catchy lines like “Hip bone connected to the back bone” provides an overly…
February 14, 2018 -
BlogFormulary Data Are History and May Not Predict the Future
Organizations often make plans for the New Year, and reflections on the past year are typically part of this…
January 11, 2018 -
BlogWhen Payers Think Value-Added Services Subtract Value
Perhaps you remember the “But wait! There’s more!” line from the Ginsu knife ads. Or maybe you recall anxiously…
December 14, 2017 -
BlogHow Payers Value Value-based Contracts
Value-based contracts between payers and manufacturers are in vogue. From the payer’s perspective, paying for performance by getting reimbursed…
November 7, 2017 -
BlogWhen Payers Can’t Afford Manufacturers’ Savings
The Marshmallow Test — giving a young child a choice between eating one marshmallow now or getting two marshmallows…
October 12, 2017 -
Blog3 Things (Beyond Products) Health Systems Want From Manufacturers
Manufacturers can bring truly innovative drugs and medtech to market. But to health systems, it’s not just what manufacturers…
September 15, 2017 -
BlogWhy Payers Love Crowded Markets
Some people dislike or even fear tight spaces, like crowded elevators. But for payers, there are several reasons to…
August 10, 2017 -
BlogOn Payers’ Views of Off-label Use
Off-label use of drugs and medical devices is legal and very common. Once a manufacturer has demonstrated to the…
July 12, 2017 -
BlogPutting the Pieces of Formulary Decisions Together
Though all the king’s horses and all the king’s men couldn’t put Humpty Dumpty together again, it’s pretty easy…
June 15, 2017 -
BlogManufacturers’ and Payers’ Fixes that Fail
Manufacturers and payers are guilty of making quick fixes that address a symptom but not the underlying problem. Sure,…
May 11, 2017 -
BlogWhy Payers Help Successful Brands Succeed
In the dance between manufacturers and payers, brands that initially achieve commercial success often become more successful. There is…
April 13, 2017 -
BlogWhen Payers Shift the Burden of Oncology Market Access Decisions
Cancer drugs: New products and uses and guidelines — oh my! Payers historically have avoided aggressive utilization management of…
March 16, 2017 -
Blog7 Prior Authorization Myths Smashed
Payers’ use of prior authorization (PA) is often discussed but seldom fully understood. Myths and misconceptions related to PAs…
February 9, 2017 -
BlogLet’s Go Places Payers Want To Go
Here’s a bumper sticker: Honk if you know what your customer really wants. For a manufacturer, successful payer marketing…
January 13, 2017 -
BlogHow Payers Measure Management and Manage Measurement
Measurement is commonly linked with good management. You may be familiar with the old saw in carpentry measure twice,…
December 15, 2016 -
BlogWhen Payers Think Non-Inferior Products are Superior
Yes, sometimes payers view “non-inferior” products as being superior. Just how they react to new products with evidence of…
November 11, 2016 -
BlogA Funny Thing Happened on the Way to a Formulary Decision
While P&T committee meetings are typically serious and professional, like all social situations, funny things can happen. Pharmacy and…
October 13, 2016 -
BlogTo Kill a Mock P&T/HTA Committee Meeting
A mock pharmacy and therapeutics (P&T) or health technology assessment (HTA) committee meeting is one of several methods manufacturers…
September 15, 2016 -
BlogWhy Payers Think a “Significant” Difference May Be Insignificant
An observer may ask whether a difference is significant. This seemingly simple question requires a nuanced answer, because there…
August 11, 2016 -
BlogAn inconvenient truth about payers not paying for convenience
Convenience products are those that are relatively easier to use than alternatives already on the market. Products that require…
July 14, 2016 -
BlogPAYERS’ LOVE-HATE RELATIONSHIP WITH NEW STUFF
Change in health care is constant, and with that change payers expect new stuff — new products, services, evidence,…
June 16, 2016 -
Blog5 Reasons To Question the Value of the Value Equation
Value. It is always wanted, commonly discussed, occasionally conceptualized, yet infrequently operationalized or measured correctly. But if optimizing value…
May 5, 2016 -
BlogBudget Impact Analysis – Is the Juice Worth the Squeeze?
Payers often conduct a budget impact analysis to assess the affordability of a new offering, such as a drug,…
April 14, 2016 -
BlogReal-World Evidence – What Payers Really Really Want
Real-World Decisions In essence, payers make formulary management/medical policy decisions based on three criteria: efficacy, safety and cost. When…
March 10, 2016 -
Blog5 Steps When Revisiting Your Payer Marketing Strategy
Are Payers Just Not That Into Your Brand? You’re trying to optimize market access for your brand, yet you…
February 12, 2016