Photo credit: Erica Berger

Participants in this roundtable explore how digital forms of data are poised to illuminate the reimbursement pathway, as market access gets its closeup.

As in other industries, the mountain of data accumulating provides both challenges and opportunities. Healthcare is big data’s fastest-growing sector, expanding by 48% every year, noted Leilani Latimer, head of marketing and partnerships for Zephyr Health. “But 80% of that data is unstructured,” she added, “so it’s difficult for customers to get their hands on the right data — and when they do, it’s a challenge to operationalize it.”

Among the most complex unstructured data are clinical in nature, like the notes doctors enter in EHRs. Add to that insurance claims databases, formulary info, and real-world evidence, and you get a diverse mosaic that industry pros affectionately refer to as market access data. Market access experts, and their insights, were once more isolated among the pharma marketing disciplines.

“People are now asking how to move market access insights farther upstream, because commercial decisions are based on where you’re placed on a formulary,” Latimer added.


The industry has come to a point where all the incentives — around value, balancing access, and innovation — are aligned, added Brian Corvino, SVP, global consulting services division, Decision Resources Group. “Boardrooms once only talked about the science and the promotional effort behind products,” he said. “Now the conversation at investor presentations has pivoted toward value.” This change is affecting both stock prices and policymaking.

Technology is fostering that pivot, bringing market access out of the corner. Peter Weissberg, VP of market access at Intouch Solutions, sees technology as a key differentiator to enabling integration of patient needs and therapies being brought to market. “Putting technology in the hands of patients and consumers can help us all — even those who don’t face patients,” he added. 

And speaking of those that are patient-facing, health systems want to leverage their data to help pharma and device companies to bring innovative treatments to patients, said Dr. John Chelico, chief research information officer at Northwell Health. “Being able to present to our physicians how we’re using a drug, both on label and off label, is really changing the conversation,” he said. “We couldn’t do it before the ubiquitous use of EHRs and computerized physician order entry.”

Another rich source of data can be found in employer well-being programs, said Dr. Madhavi Vemireddy, chief medical officer at Active Health Management, Aetna’s disease-management unit. “Employers are getting information on lifestyle risk factors and what type of behavior change individuals are ready for. We use that to create action plans so members can achieve healthy behaviors.” 

What Vemireddy describes is a more holistic view than just thinking about medications. “It’s figuring out how care managers and coaches can work with physicians to fill that white space between office visits. How do we leverage technology to do that?”

Following up on this point, Weissberg noted a shift, as the market access value proposition to the payer, part of organizations is very much informed by this holistic patient journey. “Historically, we have been in a value proposition that’s been safety, efficacy, cost. Those are the core pillars of a payer value proposition.” Other pillars need to be added now — patient centricity and connecting data between office visits.


“Understanding the patient journey is the story of our life,” said Corvino. “We’re in chapter one of a multichapter book, and there’s so much excitement around claims and EHR. But those data sets only represent 30 minutes of one day in a month.” What will be really powerful, he said, is the digital exhaust we’ll all produce over the next several years, in everything from mobile to sensors.

Continuing his analogy, Corvino said, “Chapter two will be capturing and linking data resources in a meaningful way — and doing that longitudinally is hard. Chapter three — the holy grail — is applying machine learning, algorithms, and other insights so we can actually predict when someone’s going to have an event and then prevent it from happening.”

Corvino also brought up what he called “the principal agent problem” in healthcare, where the selector of an intervention differs from the payer, which is different from the user. “So you have institutionalized asymmetric information among three entities,” he said, “and when something happens you need to find a way to connect and communicate and accelerate information.”

In Zephyr Health’s recent survey of industry leaders, 74% of respondents said they need marketing access insights to understand reimbursement. “It’s a problem at the most basic level,” Latimer said. “A patient goes to pick up a prescription, finds out it’s not on the insurance plan, and can’t pay for it. All those other issues — such as adherence — fly out the window. The patient journey just ended.”

Chelico said he’s often faced with sudden changes in formulary that require patients to pay out of pocket. “I’m assuming that when they make those decisions, they’re not thinking of the patient,” he said. As for affecting change in the mind of the prescriber, “You have to get in the head of a physician to understand how decisions are made. When physicians are writing a prescription, they don’t necessarily have all the data.”

Photo credit: Erica Berger


Real-world evidence can offer the pharma industry deep insights into developing and marketing safe and effective treatments. But the sheer volume of data seems daunting. Chelico acknowledged it would be a huge partnership if pharma could provide physicians with real-world point-of-care data. “It could help physicians make the right decisions,” he said, “but unfortunately they can be skeptical, wondering ‘What’s pharma trying to sell me?’”

But he’s convinced pharma still has an opportunity. “Northwell’s a well-to-do health system, but we don’t have the resources of the big industry partners. We need to partner with the industry, or with our insurance companies or payers, to do things we couldn’t do on our slim margins.”

Weissberg noted there is a lot of buzz around the idea that pharma should make data available even if it drives a decision to a different drug. That, he suggested, could help gain credibility.

Data sources also need to be taken into consideration. “You can’t extract insights if you don’t triangulate real-world evidence with data from other sources,” Latimer said. “What’s valuable to a physician is when a pharmaceutical or medical device company presents new medical evidence based upon data from combined sources.”

Another source of data is in patient-to-patient conversations. “In our social listening at Intouch, we’re seeing that patients are incredibly willing to share — way beyond what would be within the HIPAA confines,” Weissberg said. “We believe that’s a treasure trove of opportunity for payer and provider organizations.”

Chelico agreed, adding, “For certain chronic disease states and terminal illnesses, online communities are actually better data sources for families and parents than their own physicians. You learn what works and doesn’t work on the playground faster than you could learn anywhere else.”

“It’s the trust factor,” Latimer said, “because when you’re on the playground the payer isn’t listening.”

“Nor is the person who’s making money off the product,” Chelico added.

Photo credit: Erica Berger


“You have to translate the data into insights,” said Vemireddy, “and then make those insights actionable by connecting them to recommendations or educational materials.” And you gain the patient’s trust by tying the recommendations to a trusted resource, such as a physician or coach.

New consumer expectations, such as cost transparency, are affecting today’s market. “We’re seeing patients raising their hands and expecting a certain experience,” Weissberg said. “We’re playing that back to our manufacturer customers and saying, ‘that’s what you need to deliver.’”

Corvino said physicians now say they would like pricing transparency so they can make better decisions for patients, adding that the AMA just called on manufacturers to include prices in DTC ads.

There’s room for improvement in the DTC space, Chelico agreed. “Pharma companies are trying to leap over decision-makers and prescribing physicians and get patients to ask about medications that may not be appropriate for them. It adds to the providers’ skepticism.”

Photo credit: Erica Berger


Chelico pointed out that patients will do whatever they can to follow the recommendations of a physician they trust. “As a physician, that’s great,” he said. “But how do you get information in the hands or minds of the physician when they’re writing prescriptions?”

“That’s the challenge,” Latimer agreed, “especially for a pharma company that has new information, but is no-access.”

To allow that access, Chelico proposed “a registry of pharma company insights that we can deliver, beyond what we get from traditional clinical trials.” That could be a way to gather all the information, including evidence-based literature, and personalize it for the individual physician.

With certain strategies, Latimer’s pharma and medical device customers see success. “It’s when they have the right data on the commercial side and get it to the right physician through the right channel,” she said. “Physicians want messaging that resonates with them through channels that resonate. It’s very much omnichannel.”

“Some of our conversations with pharma are done in the light of evidence-based care,” Vemireddy said. “It’s not ‘I’m promoting my brand versus this other brand,’ it’s ‘Let’s identify the population that should have, say, a pneumococcal vaccination, and drive compliance.’” And in a case like that, omnichannel means also pointing members to the nearest MinuteClinic, where they could get vaccinated, and attaching digital coaching to explain why it’s needed. “You’re helping people get the right evidence-based care, while also layering in what’s on formulary at the least-out-of-pocket cost, and deciding which brand will work best for them.”

Data will also play a major role in genomics and precision medicine, according to Chelico. “Finding the right drug for a patient will be very data-driven. We’re already seeing that in cancer treatments and with certain cardiovascular drugs. Passing along that data would be really helpful to physicians.”

Photo credit: Erica Berger


Weissberg noted the odd juxtaposition between population health management and precision medicine. “Are we going to be making decisions about population health and moving away from precision medicine?”

As for whether population health detracts from patient centricity, Vemireddy said even population health starts at the individual level. “We assess an individual’s current state and what would it take to reach their ideal,” she said. “Then we come up with an aggregate of all patients to see the most opportunity in the population, whether it’s driving adherence or tailoring interventions.”

With five million patients in their database, Northwell Health has many subpopulations: different socioeconomic areas, insurance carriers, races, ethnicities, and more. “For precision medicine we need a significant number of folks in a particular group,” Chelico noted, “and we get the numbers we need when we put the data together.”

It’s the population health approach that allows you to drill down, suggested Weissberg, adding, “In a way, the term ‘population health’ does a disservice because it implies a broad stroke.”

“It’s sort of a generic approach, but it’s not,” was Latimer’s input. “You need the macro view to understand the size of the problem, and the micro view for hyper-targeting — for research and messaging, and from the treatment perspective. Because of the precision, you have to make sure the new science gets to the right treater and patient.”

And the value proposition is completely different. “People say one of every three dollars in healthcare is waste,” Corvino noted. “Think about chemotherapeutics. For years we threw chemotherapy at patients and hoped it would work. With hyper-targeted therapy, now we can say with certainty this particular drug will cure you — but there’s only 3% of you.

“When the first gene therapy that’s a cure is launched in the U.S.,” he continued, “it’ll be very expensive — but it will have a tremendous value proposition. We need to be ready to communicate that value, especially when so much of what we used to do was a waste.”

“Medicine is an art and a science,” Chelico noted. “ You can’t be draconian about the data and derive results that aren’t in the context of the patient. But if you get that secret sauce of the two things together, you can have a big impact on physician communities and patient care.”


Joining market access to data and technology requires staff upscaling — finding the right talent and training people effectively

Dr. John Chelico, Northwell Health: “For data-science jobs in healthcare, you don’t just need people with technical knowledge. Sure, they should know how to bring large data sets together and derive knowledge through AI or machine learning. But they also need to be very practical in their recommendations and their visualization of the data to make it operationalized and actionable.”

Dr. Madhavi Vemireddy, Active Health Management: “It’s got to be a multidisciplinary group. You need the insights of a data scientist along with clinicians who can apply those insights and coaches or care managers or nurses to implement the interventions.”

Leilani Latimer, Zephyr Health: “We found that companies are upscaling, rescaling, or re-engineering their commercial teams over the next three years. Some are considering a combined sales and market access role to have customer-facing reps who understand market access.”

Peter Weissberg, Intouch Solutions: “To create omnichannel communications, you need domain experts and intermediaries. As the depth of the domain expertise increases, the experts are diverging from those who lack the knowledge. That’s where people like hospitalists come in.”

Brian Corvino, Decision Resources Group: “People who are really great at algorithms can’t be expected to translate that into impact. We recognize that people work differently. Our data people apply their science to subject matter expertise. And then we pull all that forward in an intervention or impact platform.”


The importance of sharing data came up often, and two participants offered cogent examples.

Dr. John Chelico of Northwell Health lamented the difficulty of exchanging information when vast amounts of patient data — in portals, PHRs, and the like — exist outside the four walls of healthcare organizations.

“It’s a disconnected network,” he said. “You get access to a patient portal from your doctor, you have another one from your insurance company, and another from an urgent care clinic. None of it is tied together.”

The healthcare industry does suffer from a lack of standardization, agreed Zephyr Health’s Leilani Latimer, who suggested the global travel industry offered insight. “Today we can compare all the flights on a single screen,” she said, “because the industry came together and settled on one standard for sharing data. We’ve had this access for 20 years now.”

Chelico offered an example that dates back even farther, to the change in the banking network in the 1980s that allowed ATMs to function. “That gave us full access to our bank account information around the world,” he said. “Just paying a bill used to cost several dollars. Now it’s a fraction of a cent. Look at some of the ways we interact in healthcare: writing a prescription, filling it, delivering it — all that costs money that could be spent on patient care. We’ve gotten better at e-prescribing, but we still can’t share data in other places.”

Chelico’s proposition? A third party that would collect information, make sure it’s unbiased, and then present it accordingly. “If it comes from a pharmaceutical company channel,” he noted, “it’s going to be met with skepticism.”

Sharing data offers a tremendous opportunity, Chelico said. “The industry has a chance to improve outcomes simply by communicating information. That is the next frontier.”