Quality Value Proposition Is Key to Improving OAB Care, Coverage for Older Adult Members

Norm Smith, principal payer market research consultant, emphasizes the importance of ensuring market access teams are equipped with quality value propositions which demonstrate the clinical value and cost benefits of overactive bladder therapy options for older adult member populations, particularly those in long-term care.

This interview is part of the series,"Navigating Clinical Challenges, Improving Care for Patients With Overactive Bladder."

Read the full transcript: 

Welcome back to PopHealth Perspectives, a conversation with the Population Health Learning Network where we combine expert commentary and exclusive insight into key issues in population health management and more.

In this episode, I speak with Norm Smith about the burden of overactive bladder (OAB) on older adults, and what access teams can do to ensure proper care and coverage.

My name is Norman Smith. I was in the pharmaceutical industry for 44 years, and I learned so much from the industry and field. I worked for some great companies like Merck, Genentech, and J&J. In the last 20 years of my time in the industry, I opened my own company, Viewpoint Consulting, located in Northeast Philadelphia.

This was the right time, right place. Companies back in 2000-2015 were still at varying levels of understanding of the importance of nonphysician decision makers in market access for products. What we were doing there was a ton of market research. I was doing it for major companies and small companies. It varied tremendously. I sold that company in 2016, and since then, I've been involved in several very interesting cases as an expert witness. I've also helped arrange some ad boards in some rare disease categories.

Thank you, Norman, and thank you for joining today. Overactive bladder and urinary incontinence create a substantial burden for older adults, especially those with comorbidities. Can you discuss what makes caring for this population so challenging?

On a couple levels, it's challenging. Obviously, there's the question of multiple drugs, and multiple comorbidities that you treat with those drugs. A large percentage of patients with OAB are female.

Many times they have access to a primary care physician, but not to a specialist. This debate went on for a while: are OAB drugs primary care, or do you really need a specialist for this? From the payers’ position, they would want you to stick with the primary care.

Then the question is the amount of time the primary care provider has to explain what's happening physiologically and what the drug will do to help, as well as counseling them about side effects. It would be great if they also had a community pharmacist involved in that counseling. Some of the pharmacy chains—particularly Walgreens and CVS—have really targeted this patient population and come with pharmacists that are trained in counseling for that specific condition. That’s very helpful. I know one or two of the companies helping to train those pharmacists.

Now for the data. From the pharmacy side, they’ve had another duty the last couple years in giving COVID-19 vaccinations. In a busy store you're filling 300 prescriptions a day, and you're giving vaccinations. That's tough. Whenever I've been in the store and talk to a pharmacist about it, they just roll their eyes, because they're being asked to do so much more than they were before.

The counseling is important. Several of the companies with branded products in this category are providing support programs around the products, which can also be a big help. In my experience working with these products, compliance is not the problem, because every couple hours they get a reminder they've got to do something about it, so that's not the issue. The issue is: what do I take, and how do I tolerate the potential side effect?

Thank you. What information does the access team need for a marketing plan for long-term care?

It took a while for everybody to learn what needs to be done. The first thing needed is a value proposition. A defensible value proposition needs to be developed. You can't have something that's what I used to call an “internal fairy tale,” meaning it’s great when you're in the meeting room and not in front of a customer. People strongly believe it’s a great product, and nobody's questioning that part inside.

Unfortunately, it's the job of many of the nonphysician decision makers in market access, on the payer side. They ask a lot of questions. You not only have to have a well-developed value proposition, but  that value proposition needs to be defensible, tested, and challenged internally without taking somebody's head off. It's not a discouraging word, it's making the muscles stronger. Right?

Then a slide deck comes together. It's not just a slide deck from a physician inside the company; it's also a slide deck that can be used by the account managers. One of the things that I've learned and seen over 20 years is the account managers are focused around contracts, pricing, and formulary access. All of that is good, but they must have enough clinical background to be able to explain the value proposition. That's where a lot of companies fall short. They haven't taken the time to train these people in the clinical side of making the value proposition argument. That's important.

There's a question of timing. When do you go out to these payers? Well, when you're looking for a market assessment, you can do that within 18-24 months of what your expected launch is. You must have longer term data, at least a year, to present. And what they're going to look for are things like: do people take this drug? When they do, do they stay on it? Or if they're not Medicare patients, are there programs that work around those patients?

You notice I'll flip between patient and member, but they're not interchangeable. In a population health viewpoint, you are looking at members, not the individual patient.

Many times with a branded product, you are going to have step therapy. You've done the value proposition, defended it, done the formulary access. Now you may be relegated to a third spot, because there are multiple drugs in the OAB class. So the first drug out of the shoot is generic. Second drug out of the shoot is generic. If you're lucky, you're the third drug, and you have a particular patient type to focus on and gain agreement with that niche.

Over time, with the experience of patients, providers, and then finally payers, you'll get a bigger niche. If the product can hold its own, that's the case. You can't expect to start there. You don't want to go in there, because the Medicaid population is also on these drugs, and if you lower the price too much, you'll end up paying a major league rebate on the product. You want to be able to say, "This product has value, this is why I put this price on it. Yes, I'm willing to make some pricing concessions, but I can't go crazy with this. This is not the way we're going to work as a company."

Thank you. Speaking of payers, how should payers and other organizations be addressing increasing polypharmacy rates and inappropriate medication usage?

This should be done at the formulary committee level. It should be done in the databases of drug information the retail pharmacy has. If this is someone that's in long-term care, you better make a fuss with patients having trouble tolerating products because consultant pharmacists that service long-term care facilities are very busy people.

They are often not located in one facility; they usually work in multiple. If you're going to bank on that person to do the counseling, you must reach out, and that's something that can probably be done at the territory level. Find out who those people are, because they will look at your prescription and say, "Wait a minute, they haven't gone through trials to generic products. I can save money for my boss, so I'm going to enforce that."

The pharmacist is somebody that should also hear the value proposition. Certainly a toned down variety that is not so involved on the contracting side, but maybe more involved on the pricing side.

It's a tough battle when you're entering a very crowded marketplace. My advice on this one is, accept the step care. You have to get a niche somewhere. You have to get a start. If you come in there and demand, "No, I have to be on formulary. My boss told me we'd be greeted with flowers and parades,” that is not happening. Having been involved in some of the greatest products in the industry, I can tell you I never got flowers and parades when I walked in. That's just not the way it works.

Is there anything I haven't asked you about or anything you'd like to add?

OAB is one of the main reasons people are almost forced to go into nursing homes. Now with the big emphasis these days for home care, you have to get on top of this. This is a patient education issue. You can't let yourself get to the point where every day you're ruining your clothes and urinating on yourself. You have to get ahead of it, and treatment will help you do that.

This needs to be built into the value proposition, because treatment is of value to a payer and a patient. It is better to not wait till 29 out of 30 days. You're killing your clothes and cutting down on your mobility and socialization. We’ve seen enough of that with COVID-19, by staying on top of this. That's something I can really understand, having seen it in my own circle of friends at this point in life. That's my story, sticking to it.

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