Transforming legacy approaches to understanding drug costs: An Interview with HealthPlanView’s Nicole Espinoza

Dr. Patti Peeples, CEO of HealthEconomics.Com, sat down with Nicole Espinoza, Vice President of Knowledge Management at Pharmspective, a Healthcare Knowledge Management Company and the organization behind a new platform, HealthPlanView™, designed to address transparency around the true patient cost associated with pharmaceuticals. Disclaimer: This interview is paid for by Pharmspective and HealthPlanView™.

Dr. Peeples:  We are seeing an upsurge in companies developing approaches to understand drug pricing and access to treatment, catalyzed by the growth in specialty pharmaceuticals, expansion of step therapy, and imposition of strict utilization criteria at the health insurer level. What was the rationale behind the creation of HealthPlanView™ and what is your primary mission?

Ms. Espinoza:  The healthcare landscape has evolved significantly in the past few years, in part due to the explosion of specialty pharmaceuticals and other high cost drugs prescribed for chronic or life-threatening conditions. Our parent company, Pharmspective, works at the nexus of this healthcare ecosystem and uses digital app technology to create transparency around the evolving healthcare landscape and with a particular focus on the true cost of accessing and remaining on treatment.

Our latest innovation is HealthPlanView™, which – at its core – is a platform designed to dramatically increase transparency about the true cost burden assumed by patients and payers from treatment initiation through maintenance therapy.

Why is this important? We believe that formulary tier has become a poor proxy for the cost of treatment because of the complexity of insurer benefit designs and medical policy criteria.  As you note, health insurers have expanded their use of step edits and utilization management restrictions over the past few years. The intent of these types of benefit designs is to drive prescribing of lower cost (or cost-effective) therapy prior to allowing reimbursement for more expensive treatments.  HealthPlanView™ provides transparency around the true patient cost associated with each prescription to facilitate greater clarity to patients, payers, providers, and pharmaceutical manufacturers about the access and cost barriers that matter most.

Formulary tier has become a poor proxy for the cost of treatment because of the complexity of insurer benefit designs and medical policy criteria

Nicole Espinoza, HealthPlanView™

Dr. Peeples: How exactly does HealthPlanView™ provide cost transparency to these stakeholders?

Ms. Espinoza: We know that reimbursement of pharmaceuticals is incredibly confusing, complicated by the litany of insurer benefit designs that patients must choose from.  These benefit designs layer on deductions for pharmacy and medical costs, copays for prescription drugs and doctors’ visits, and exclusions for certain treatments.  By providing more granular understanding on these nuances in benefit designs, HealthPlanView™ can create a view of the differences in patient out-of-pocket costs that are unique to each patient, payer, and treatment.  In a nutshell, we increase transparency around all of the elements that impact the patient cost burden, something that has not been done before.

Dr. Peeples: How has our industry managed this challenge of identifying true patient costs prior to this new tool? In other words, what have we been doing and what are the negative consequences associated with this lack of knowledge or lack of transparency?

Ms. Espinoza: For many years, legacy formulary tools have been focused on providing only formulary tier-level information as a proxy for cost and – in some cases – high-level utilization management data. We believe that distinctions such as “Preferred with a Step Edit” do not provide enough granularity to inform key decision makers’ understanding of how favorable or unfavorable access to a specific product is and the true impact of the cost burden associated with that product. 

Our goal is to 1) enhance understanding of drug utilization criteria such as specific diagnosis, testing, age, exclusion stipulations, and products prioritized for use prior to treatment initiation; 2) Create a level of transparency that can help users understand distinctions in these criteria across payers and between similar medications, and 3) provide specifics about the costs incurred as patients move from treatment initiation through maintenance therapy.

To put it another way, previous formulary tools have a blind spot in that they cannot bridge the gap between formulary placement and the likelihood that a patient will actually fill a prescription. Incorporating the details of a plan’s benefit design (which, of course, changes annually) has allowed us to create calculation algorithms in both Commercial insurance and Medicare to assess drug cost to the patient for each prescription filled across an entire year. By aggregating monthly out-of-pocket patient cost based on benefit design, enrollment, and policy data in our web-based platform, we are able to provide deeper insights.

At the manufacturer level, we understand that payer-facing departments, such as Managed Markets and Key Accounts strategy, need to be able to distinguish between access- and affordability-based nuances like deductibles, out-of-pocket maximums, and cost-sharing that are specific to each health plan. Without accounting for these nuances, patients that were once believed to have favorable access to a drug might realistically not be able to afford that medication and might ultimately not fill that prescription. This, of course, leads to poorer health outcomes and all of us – society, providers, payers, biopharma, and most importantly, patients themselves – have a goal to improve patient outcomes.

Those in Managed Markets and Key Accounts strategy need to be able to distinguish between access- and affordability-based nuances like deductibles, out-of-pocket maximums, and cost sharing that are specific to each health plan.

Nicole Espinoza, HealthPlanView™

In a nutshell, by providing greater transparency into true drug cost burden to patients and payers, HealthPlan View™ hopes to provide substantial context to inform understanding of the barriers to and decisions surrounding treatment choices.

Dr. Peeples: Benefit, formulary and product pricing is always changing. How does your insight tool keep up with these changes?

Ms. Espinoza: HealthPlanView™ is updated annually with Commercial and Medicare plan lists and benefit design details. Currently, the tool reflects 2019 data. On a quarterly basis, coinciding with P&T schedules, formulary data is updated. Additional updates are implemented if there are large M&A events or new product entries into a therapeutic area. Ad-hoc updates are available to any market basket requested by customers.

Dr. Peeples: What is your hope for how HealthPlanView™ will affect the business of healthcare, and specifically pharmaceuticals?

Ms. Espinoza: We believe that HealthPlanView™ will fundamentally transform pharmaceutical manufacturer contracting with payers by clearly distinguishing whether payers are easing access to treatment or simply acting as a conduit to patients with the financial resources to afford treatment.  We believe that this will alter the level of rebate incentives provided to a payer by considering the attractiveness of benefit designs offered by each insurer and the role that these designs play in the prescription volume being generated. The platform will also help customer-facing representatives and reimbursement support teams explain the challenges of benefit designs and the role of reimbursement support programs to providers.

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For more information, visit https://healthplanview.com/. The company welcomes requests for a complementary demo.