Pricing and Market Access Case Study: Medicaid Channel Strategy

Client Situation

Due to changing market dynamics—namely, increasing competition and increasing payer management in an historically high-cost but hands-off specialty category—our client, a large, global biopharma company, needed expertise and guidance in how best to defend and bolster its portfolio in the Medicaid channel. Recent organizational changes, which confounded roles and responsibilities across functional teams, complicated the client’s situation. Having partnered with EVERSANA MANAGEMENT CONSULTING on several prior managed markets engagements and knowing how experienced and knowledgeable we were in this area, the payer marketing team came to us for assistance.

Our Solution

After establishing a project plan and gaining buy-in from the client, we began by collecting client data and conducting additional secondary research on key trends and dynamics in Medicaid in the portfolio therapeutic area to analyze the situation and serve as a basis for the next work stream. Trends such as shifting of lives from fee-for-service (FFS) to managed Medicaid, growth of state Medicaid FFS preferred drug lists, changes in specialty reimbursement methodology, and use of drug utilization review boards for specialty class management, as well as wide variability in different states’ approaches to the category, all stood to significantly impact the client’s business and were taken into account as we collaborated with the client in developing the Medicaid channel strategy.

Next, we conducted extensive desk research and analysis of third-party data. Then, we conducted internal primary research to obtain cross-functional insights from stakeholders on key teams—advocacy, government affairs, marketing, account management, and reimbursement—regarding key elements of a comprehensive channel strategy: roles and responsibilities in setting Medicaid strategy, trends and dynamics in the channel, issues and opportunities, the company’s strengths and gaps in Medicaid, learnings from competitors’ approaches to the channel, and requirements for success.

We synthesized the primary and secondary research findings and prepared and moderated a full-day, cross-functional workshop, the output from which would serve as the basis for the Medicaid channel strategy. The workshop included a brainstorming session on stratifying the states, a prioritization exercise based on key threats and opportunities for the portfolio in Medicaid, two breakout discussions (one on strategies and tactics to address the key threats and opportunities and the other on state-specific plans for key states), and finally a work session on defining the critical success factors for the portfolio in Medicaid.

We then used the workshop output as the basis for a detailed Medicaid strategy, plan, and roadmap. The plan details were fleshed out during three follow-up strategic working sessions with a core group of client stakeholders. Within the plan, we established Medicaid-specific and state-specific key issues and strategic imperatives; identified risk classification criteria and classified states based on size and potential risk into high-, medium-, and low-risk buckets; and prioritized states. Finally, we developed strategies, sub-strategies, and tactics for each of the Medicaid- and state-specific strategic imperatives broken out by team/role that mapped back to the prioritized states.

Let’s face it—most categories are facing increasing payer scrutiny. If you’re preparing to launch a new product, need pricing, contracting, or channel strategy, or wish to segment and prioritize key accounts on which to focus your efforts, let us help you optimize coverage.