ACORDA

Therapeutics, Inc.

Kent Rogers
Vice President Managed Markets

How has the role of Managed Markets changed over the

last decade?
How do differences between large and small pharma
organizational structures impact Managed Markets?
Whats in store for Managed Markets?

Source: Health Strategies Group

 The two most

important stakeholders
are the CMS and
private payers

MCOs dominate private

healthcare provision and
now cover 95% of
employees

Wholesaler

MCO

PBM

Wholesaler

Retail
Retail
Specialty
Pharmacy

PBM
MCO
PBM

Specialty
Pharmacy

PBM

Prisons
Chain Drug Store

Warehousing
Retail
Chain

Mail Order
Pharmacy
Food/Mass Merch
Drug Store

HHC
Long Term Care
Acute Care
Hospital Pharmacy
HMO

Specialty
Distributors

Government
Physician
Clinic
SPP

Mail

Medical Groups
VA & DoD

Patient

Full Line
Wholesalers

Health Care Professional

Manufacturer Distribution Centers

Independent
Drug Store

McKesson Drug Company

D&K Healthcare Resources
Medis Health & Pharmaceutical Service
V.F. Grace, Inc.
FoxMeyer Corporation
Harris Wholesale

Cardinal
F. Dohmen & Co.
Par Med
Bindley Western Drug Company
Tennessee Wholesale Drug
Alabama Wholesale Drug
Superior Wholesale Drug
Kendall Drug
J.E. Gould & Co.
Behrens, Inc.
Humiston-Kneeling
Whitmire Distribution Corp.
Solomons Company Inc.
Chapman Drug Co.

McKesson Drug Company

Cardinal
AmeriSource Bergen
Morris + Dickson Co. Ltd.
Kinray Inc.
D&K Wholesale Drug Inc.

AmeriSource Bergen
Bergen Brunswig Drug Co.
Trent Drugs Ltd.
Alco Health Services Corp.
C.D. Smith Healthcare Inc.
General Drug Company
James Brudnick Company Inc.
Walker Drug Company
Albers, Inc.
Coleman, Meadows, Pate Drug Co.
Skyland Medical Supply, Inc.
Gulf Distribution
Newbro Drug Company
Eagle Drugs Inc.
J.M. Blanco
Dr. T.C. Smith Company
Durr Drug Company, Inc.
Owens and Minor Inc.
South Bend Drug Co.

H.D. Smith Wholesale Drug Co.

Smith Drug Co.
Walsh Dohmen
F. Dohmen
0

200

400

600

800

Sales $ Millions

1,000

1,200

MCOs:
Health Plans/
PBMs/PDPs

Pricing
Houses

Large Group
Practices
Unions

Hospitals

Behavioral
Health

Managed
Markets

IHNs

GPOs

Trade
Senior
care

Employers
Prisons

VA/DOD

Medicaid

MCOs:
Health Plans/
PBMs/PDPs

Hospitals

Managed
Markets

IHNs

GPOs

Trade
Medicaid

VA/DOD

1: Identify Segment Targets

MCOs
PBMs
Hospitals
Wholesalers
GPOs
SPPs

Hi
Formulary
Control

2: Prioritize Accounts

Low

Level 2 Accounts

Level 1 Accounts

Tier Differentials > $15

Co-Insurance Tiers
PAs/Step Edits
Regional/National
Influence

Tier Differentials > $20

Co-Insurance Tiers
PAs/Step Edits
Regional/National
Influence

Level 4 Accounts

Level 3 Accounts

Tier Differentials > $15

Regional/National
Influence

Tier Differentials < $15

Regional/National
Influence
Step Edits

3: Determine Contact Depth

Low
CEO

President

VP Provider
Relations

Admin
Assistant

Provider
Contracting

VP Clinical
Operations

Medical
Directors

Hospital
Contracting

Pharmacy
Director

Staff
Pharmacist

Legal
Contracting

VP Marketing

Account
Executives
(HMO)

Actuary

CFO

Account
Executives
(PPO)

PBM Client
Director

VP Public
Relations

Public
Relations
Lobbyist

VP Quality

Outcomes

Director

Case
Manager

Hi
Prescription Volume

CEO

President

VP Provider
Relations

Admin
Assistant

Provider
Contracting

VP Clinical
Operations

Medical
Directors

Hospital
Contracting

Pharmacy
Director

Staff
Pharmacist

Legal
Contracting

VP Marketing

Account
Executives
(HMO)

Actuary

CFO

Account
Executives
(PPO)

PBM Client
Director

VP Public
Relations

Public
Relations
Lobbyist

VP Quality

Outcomes

Director

Case
Manager

CEO

President

VP Provider
Relations

Admin
Assistant

Provider
Contracting

VP Clinical
Operations

Medical
Directors

Hospital
Contracting

Pharmacy
Director

Staff
Pharmacist

Legal
Contracting

VP Marketing

Account
Executives
(HMO)

Actuary

CFO

Account
Executives
(PPO)

PBM Client
Director

VP Public
Relations

Public
Relations
Lobbyist

VP Quality

Outcomes

Director

Case
Manager

Active Account Planning

Thresholds may be evident when the price goes above $400 and $700 WAC per month.

4th tier

3rd tier

2nd tier

Payer
Strategy

Build the
Value
Proposition

Prime Payer
Market

Develop
Distribution
Strategy

Develop
Pricing
Strategy

CEO

CFO

CMO

Marketing
Managed
Markets

General
Counsel

COO

Sales

CEO

CFO

CMO

COO

General
Counsel

Marketing

Sales

Managed
Markets

CEO

CFO

CMO

CCO

General
Counsel

Marketing

Sales
Managed
Markets

CEO

CFO

CMO

CCO

General
Counsel

Marketing

Managed
Markets

Sales

Managed
Markets

National MCOs/
PBM

GPOs/
Hospitals

Regional MCOs/
PBMs

Payer Contracting

Government
Affairs

Product Pricing

 National Committee for

Quality Assurance (NCQA)

National Quality Forum

(NQF)

NCQA-HEDIS*

URAC (Utilization Review

Accreditation Commission)

Ambulatory Quality
Alliance (AQA)

Integrated Healthcare
Association

Pharmacy Quality Alliance

(PQA)

Hospital Quality Alliance

(HQA)

Hospital Compare

National Quality Forum

(NQF)

Pharmacy Quality Alliance

(PQA)

Joint Commission
Accreditation of Healthcare
Organizations (JCAHO)
AMA Physician Consortium
for Performance
Improvement

Bridges to Excellence

Medicare Physician
Voluntary Reporting
Program (PVRP), now
PQRI
HHS Value-Driven
Health Care Initiative

Increase in Federally Mandated Rebates 15.1% to

23.1%

Medicare Part D Donut Hole 50% share

Medicaid Eligibility will be expanded

Changes to the definition of AMP resulting in a Higher AMP

PHS Program participation will expand Federal

Ceiling Price legislation

Managed
Markets
National
MCOs/PBM

GPOs/
Hospitals

Regional
MCOs/PBMs

Payer
Marketing

Trade &
Distribution

Payer
Contracting

Product
Pricing

HEOR

Business
Development

Public
Policy

CEO

CRO

VP Accounts
VP Contracts/
Pricing
VP Trade/
Distribution

CFO

CMO

General
Counsel

CCO

Marketing

Sales

Managed Markets experiencing increasing control over

levers of corporate revenue
Span of responsibility for Managed Markets departments
expanding with the changing healthcare environment
Both large and small pharma organizations need to adapt
their organizational structure to accommodate these changes