Life Sciences

Sales, managed care synergy vital in health reform evolution

Medicare & Reimbursement Advisor Weekly, December 11, 2009

When you are considering sales and managed care marketing and account team synergy in the next era of healthcare reform, look to key states and how commercial and Medicare plans and employers interplay. To help think about this, MRAW took a look back at plan enrollment and market share in 2007, one year after the last major health reform—Part D.

Our focus was Florida and Miami-Dade county—a bellwether area for healthcare policy and, to a degree, pharmaceutical strategy. Upon close inspection of Florida’s largest county, Miami-Dade, we noticed that six plans controlled almost 90% of the local Medicare market share. Boosted by HMO enrollees from the 2005 acquisition of CarePlus, Humana had the largest enrollment share in the county, with more than 86,000 enrollees through its stand-alone and Medicare Advantage plans—created out of Part D. CarePlus had an open formulary, but Medicare members would be subject to Humana’s formulary in this scenario. United was second in market share with most of its enrollees from its stand-alone PDP. Interestingly, two local plans ranked ahead of national players. Ranking third was Leon Medical Centers, an integrated system with a PDP product called Leon Cares. An integrated system such as Kaiser could hurt a pharmaceutical company if its product is nonformulary. Preferred Care Partners and Envision Services company ranked fourth. WellCare and WellPoint fell next. Health plan enrollment numbers such as these can be useful for managed care teams interested in capitalizing on strong formulary placement but also in approaching the right companies and employers as policies shift to focus on prevention, wellness, and, perhaps, a new benefit. For example, if your best-selling drug’s formulary placement is better than your competitors’ among the top Medicare plans by enrollment, you might consider adding account or sales representatives to this market to ensure that employers and physicians understand how important these plans are to their practices. For products not on the formulary for any of the top-enrolling plans, consider taking sales reps out of this market and redeploying them to other states or counties. With many questions remaining about health reform, how to allocate or reallocate resources may not yet be clear, but taking a local customer approach may be pivotal, depending on how each state and market respond.