Pharmas Urged To Take Committed Steps Along The IDN Pathway

Integrated Delivery Networks can have a major influence on the drug classes prescribed by physicians affiliated with their network. IMS urges pharma companies to approach these increasingly important partners in health care delivery with strategies that are significantly different than those they've used in the past.

• Pharma’s inability to recognize when IDNs are causing differences in product utilization is one of the major challenges for companies in the US.
• Even if there is a tendency to overestimate how strong and organized most IDNs are, they are a major influence in prescribing practices today.
• Pharma does not help itself by failing to help the health system achieve its quality goals or understand the population goals that IDNs set for themselves.
• A dilemma arises in staying "above-brand": not favoring its own class or drug can bring the danger that the pharma company is doing more to help the competition than itself.

The number of Integrated Delivery Networks (IDNs) is fast approaching the highest number the market can expect to see. The next stage – which has already started to happen – is the consolidation among the 900 or so IDNs. “We expect to see more of that,” IMS Consulting Group senior principal Elizabeth Powers tells IN VIVO.

Fellow IN VIVO interviewee, IMS Health senior principal John Daly, notes that the percentage of physicians in the US who are part of a corporate provider network or IDN varies greatly across regions and specialties. But IDNs, comprising inpatient and outpatient facilities and providers that work together to offer a continuum of care to a specific geographic area or market, can have a major influence on the way that the physicians affiliated to that IDN treat a disease state or therapeutic area. This in turn can have a big effect on which classes of drug are used and therefore the local commercial environment for a particular brand.

In some instances it’s a case of top-down decision-making at the IDN, and a function of the way in which it educates its affiliated providers to treat this or that disease. But IDNs can also have a less formal influence, in elements like recording patient satisfaction, say, or measuring certain metrics or key performance indicators (KPIs) in diabetes and indirectly but powerfully relating to readmission rates and medication adherence. But in cases where IDN-affiliated physicians are being caused to treat differently, pharma companies today require the ability to identify the practice and find out why, and then respond with new appropriate strategies.

“The ability to recognize when IDNs are causing differences in product utilization is a big challenge for pharma,” says Daly. “A major struggle in the US comes from not having the capability to identify and quantify that influence. It may be creating a favorable environment for the class of the drug by driving physicians toward utilization, or it may be unfavorable to the class, therefore creating reduced promotional response, brand uptake or pull through for the pharma co.”

Influence Of IDNs On Prescribing

There’s a belief that IDNs are highly capable and have a consistent influence in this respect, but IMS Health findings show a more dynamic picture. For instance, many IDNs’ EHRs are not integrated, and for this and other reasons, IDNs may not always be aware of the prescribing influence they are having out in the community.

“It’s a very interesting dynamic,” says Powers. “A lot of what you read tends to point to IDNs being highly organized and aware and to be driving the influence that they are having. There are definitely some of those out there. However, many are either not aware or are wrong about what influence they think they are driving, and how providers are behaving as a result.”

But while it is the case that most people tend to overestimate how strong and how organized most IDNs are today, they “absolutely are influencing prescribing today” she adds. The IMS Health principals recalled the example of one IDN whose affiliated physicians were managing their prescribing in a particular therapeutic area in a highly consistent way. Other physicians in that same community were less consistent, although they were all influenced by the same payers.

On talking to the IDN pharmacy director, IMS Health found that all the IDN’s medical therapy pharmacists had undergone a certain type of training and they were simply influencing the physicians’ choices based on that training “in a highly consistent way and very organic way,” says Powers.

At another IDN, which was prioritizing a minimization of hospital readmissions, the affiliated physicians were observed as prescribing 60% more of a specific class for a particular therapy area (TA) than other physicians in the same local community. Pharma companies that are unaware of such influences in the communities they serve would then react by putting in exponentially higher efforts in that community.

Implications For Pharma Of IDNs

Here is where problems for the industry arise. Daly notes that there has been very little measured ROI for key account managers engaging with IDNs, partially because of a lack of a framework to do so.

Powers points to another worrying scenario. “There’s a big topic around pharma showing up without the right value proposition or the resources to help the health system achieve the quality that it is looking for, if it is, say, trying to eliminate readmission rates.” The question is, does pharma have the resources for this? Further, is it able to understand the population goals that IDNs set if the IDN is working in a way that there is potential for value?

“Denying reps full access to physicians is effectively stabbing the heart of pharma’s commercial model.” – Elizabeth Powers

The fact is that there has not been a framework to measure the influence of IDNs on prescribing patterns. But pharma is equally aware that a one-size-fits-all approach will not work, and merely hoping that the local account manager will somehow be able to align the resources and IDN engagement accordingly is not a worthy plan. And what certainly won’t work is account managers behaving like reps, says Powers.

Two things have triggered pharma’s interest in IDNs.

The first is that IDNs are saying that whatever the disease area, pharma reps can no longer have full-on access to physicians. “That is effectively stabbing the heart of pharma’s commercial model – and pharma is going to react,” says Powers. Part of the manufacturer’s reaction is fairly immediately to augment its field force with key account managers (KAMs) in a bid to vary its behavior.

The second is the realization by pharma companies that they need to think about who they are sending to engage with the IDNs, and what they are bringing with them. “What we see is pharma companies getting undermined because the account managers are pushing the brands and ‘going in like a sales rep,’” Powers explains. Others say they are not going to talk about brands at all, and stay in an "above-brand area" while combining that with IDN insight. But the danger of not favoring your own class or drug over another is to do more to help the competition than yourself.

Adjusted Time Lines For Results

As to time lines for results, more and more companies are establishing account managers, but they are still expecting to get results on the same time line as reps achieve. It’s been historically true that, add a rep and volumes go up immediately. But IDN decision-making is very different. IDNs are looking at where they have a patient pathway, and can take six to 12 months to decide whether they are going to include a drug on that pathway. That decision then sticks for another six months or longer, typically.

For pharma companies with a new drug on the market, getting the buy-in of IDN administrators happens in steps. They need to prep the IDN, that is, make early contact and understand the IDN’s unmet needs, backing it up with specific data and real-world evidence.

But it can be a tightrope, and the prepping needs to be done much earlier than is happening today. The earliest account managers come now is typically a year out from launch. There is benefit in thinking who at the IDN is going to be influential and how to engage with those decision-makers – and that goes for all parts of the market. Again, the initial steps may not be around a branded product but around the disease area, so that the pharmas can understand the unmet need.

What An IDN Wants

Once a pharma product is on the market, IDNs that are interested in working with pharma are looking for the pharma company to be engaged with them in a way that is operationally integrated into the IDN workflow. They also want the pharma company to be consistent and committed to a particular time frame of working with the IDN, from which it will not back away.

Powers’ belief is that, “Pharma is doing a fair amount of damage to itself by launching into a partnership or an engagement only to undo it six months down the line because of budget cuts or shifts in strategy.” This, she says, is beginning to wear on the IDNs.

As for payers, they have expressed interest in engaging with pharmas around portfolios of products within a single TA. “They really want the one-stop shop,” Powers notes.

Who To Approach

Who the pharma company should talk to is one of the main challenges, in Daly’s view, and it can change according to the health system. “It’s a multidimensional question and it depends on the capabilities of the pharma organization. It also depends on the therapy area, and the stakeholders at that IDN, that is, do they have D-suite level clinical experts who are looking at standards of care and are engaging in that TA?”

There are often other influencers and key opinion leaders (KOLs), and certain pharma companies have an “earned access” at the IDN because of the way they’ve presented their sales force or because they have been more balanced around patient needs. Others, who do not have this, may be locked out. “The basic question to ask of IDNs is: Do they call on their physicians to treat differently? And if the answer is no, it provides the framework for pharma companies to engage with them,” says Daly.

“IDNs do not always pick brands per se, but the issue we have seen is that the IDN is influencing at a class level, at a regimen level, and at a standard of care level,” Daly continues. Many pharma companies fail to see that; all they want is for the IDN to drive their brand. However, the IDNs have to serve so many different payers, and “their influence does not go directly to picking brand winners and losers.”

IDNs’ use of generics needs to be watched, however. “We have measured systems that have over-utilized and kept the population broadly on generics for a longer period of time than clinically may be ideal,” says Daly.This is clearly detrimental, but the way to address this issue is to look at it from the IDN’s perspective, not the pharma's perspective. IMS Health measures this with machine learning and advanced analytics, sometimes over a period of weeks to identify if the IDN actually causes its provider to treat differently in the community that it is serving.

An IDN’s Criteria Of Success

The business model of IDNs varies tremendously depending on what they are trying to achieve. IDNs that participate in CMS Accountable Care Organization payment models, are actively measuring satisfaction and the 33 quality metrics for ACOs. Other systems’ value propositions may be on cost and limited line pharma utilization, that is, using more generics in the community.

Daly puts it another way, “If a system is influencing providers to not use your class of medication, they are effectively avoiding your class,” he says. But companies that are invited to work with IDNs on, say, a compliance and adherence partnership, should also be wary. Their first instinct is to jump at the chance of working with an IDN and helping build value around a product. “But the reality is that the company would be helping that system to think about the issue and might thereby hurt their own brand performance.” As Daly describes it, they would be helping to drive patients away from your product’s growth opportunities in that market because of “the way you chose to engage.”

This doesn’t mean that pharma should not have a “complete lens” on quality, says Daly. “But if you knew that the system was avoiding your class, your engagement model would naturally be to understand the barriers for the class. In other words, to find out what is preventing the IDN from recognizing the target patients for your class and activating the class to reduce costs or improve quality,” he explains.

Elsewhere, merely putting new KAMs in place and giving them new resources will lead to a less than measurable ROI. Powers says, “What we are trying to do is get IDNs in the position where they can responsibly prescribe drugs – that’s something that only a few companies have asked IMS Health.”

She continues, “Even fewer have cracked it, and there has even been some retrenching among companies who went out big at first, only to question their own motives some way into the piece. You can’t dramatically pull back once you’ve entered.”

“Before investing in new roles, understand which stakeholders are influencing your therapeutic area and what they want to achieve.” – John Daly

Similarly, not being in the system is not an option. Ignoring IDNs is not a viable strategy, says Daly, highlighting the drive by CMS – via multiple payment models – to move from fee for service to fee for quality. “Even if the efforts weren’t designed well or weren’t measurable, the outcome should never simply be ‘We’re going to stop.’”

How To Play It For Pharmas New To The IDNs Game

So what strategy should pharmas pursue with IDNs?

“Go slow. Before you invest in new roles, you need to understand which stakeholders are influencing your therapeutic area and how, and what they want to achieve,” says Daly. “That’s the foundation of everything.”

He recommends a quant and qual approach: once the pharma has measured how much business the target IDN controls, it next can start to understand what it is trying to accomplish. “Then in a highly informed and synergistic way, with the right role mix, and right real-world – multifaceted – evidence, it has to show up with a different set of quality and cost capabilities,” he adds.

“It’s not a really deep investment, just a very thoughtful, measured and committed investment.” But you can’t ignore IDNs. “The pharma industry has to show up with the right value proposition to help IDNs achieve their goals around quality. Do not underestimate the frustration among IDNs regarding their willingness to continue listening to pharma,” Daly says, sounding a warning.

Pharma needs to remember that five to 10 years out, this is likely to be an all-or-nothing game as IDNs and payers consolidate, says Powers. So pharma companies must start getting it right as of now.

They also need a quantitative ability to understand what is going on at IDNs in terms of their influence on prescribing. “Basically, a change management effort has to go on. This is not a brand thing, but pharma does need to ensure everyone is aligned on where this is going,” Powers explains.

“Quality in an outcomes-based pharma environment: that’s where we are headed,” says Daly. “We can lead or we can be dragged, but we have an opportunity. Embracing generics for the relevant part of the population is a real example of what it means to lead. This is not all doom and gloom, it can be a very positive thing. More broadly, it’s about long-term outcomes for the population, and that changes the value proposition for the individual branded agent.”

This would elevate pharma to the extent of giving it ability to validate the additional expense and to earn the space for these agents, say the IMS experts. It changes the arena of what is the actual value proposition. With this style of approach, pharma has a chance to be a key component of higher quality even at a lower cost, contributing to broad improvements in outcomes and population management.