Coverage decisions are made by people who do not publish them
A healthcare practice inside a consulting firm was advising clients on a new class of medicines coming to market. Its advice depended on how insurers and pharmacy benefit managers, the organizations that decide what a health plan pays for, would treat the class. Everybody could read the clinical trial results. Almost nobody could read the committee that turns those results into a coverage decision.
That decision turns on budget impact, on what the new class displaces, and on how similar classes were handled when they arrived. None of it appears in a trial readout, and the committees that make it do not publish their reasoning. The practice also needed a view it could hold continuously, rather than one it assembled from scratch for each client.
We put payer and market access people in one room
We convened a round table of former payer medical directors, pharmacy benefit leads and market access directors: the people who have sat on committees deciding coverage, and the people who have argued in front of them. It was scoped for the practice as a whole rather than for one client question, because the answer needed to last longer than a single engagement.
The session worked through how comparable classes had been handled when they arrived, since the treatment of the last arrival predicts more than any projection. Where the payer side and the access side disagreed, the disagreement was argued out in the room, because that gap is where the negotiation actually happens. Every participant cleared our compliance framework before the session.
The practice now opens with a position on the class
The session produced a working account of how the class would likely be treated, with the conditions and the comparable precedents named. It also changed what the practice had been telling clients. Its message had centered on clinical differentiation; the payer voices pointed at budget impact and the order in which new treatments are taken on.
That is a harder answer and a more useful one to arrive with. Because the view belongs to the practice rather than to one engagement, the next client conversation starts with a position rather than an offer to go and find one.
