The Covid-19 pandemic continues to have a profound effect on the United States and the world. At the time of this writing, the United States has surpassed 60,000 deaths, and much of the nation is under varying degrees of lockdown. Healthcare has felt a disproportionate impact, with hospitals in some parts of the country being overwhelmed with patients while other hospitals face budget challenges, as wards of empty beds await a Covid-19 case surge that may not come. Healthcare stakeholders across the spectrum from payers/pharmacy benefit managers (PBMs) to integrated delivery networks (IDN) to specialty pharmacies (SPs) are changing processes to adapt to the new market. Pharmaceutical manufacturers must follow suit in order to meet the needs of all their customers and bring access to patients.
To better understand how Covid-19 is impacting healthcare entities, we conducted in-depth interviews with individuals at 9 health plans (3 national, 6 regional), 4 PBMs, 6 IDNs, and 2 SPs (one independent and one IDN-owned). These interviews were all fielded in the last week of March 2020. Questions differed by stakeholder type but centered on the following themes: impact of Covid-19 on business and operations, changes to drug review process and schedule, and impact on patients.
Health plans, PBMs, and IDNs traditionally review new pharmaceuticals and new indications via a pharmacy and therapeutics (P&T) committee process. Health plans, PBMs, and IDNs all noted that P&T meetings had gone virtual but with a schedule that was generally unchanged. One health plan respondent stated that they had lost multiple members of their P&T team because those individuals had been reassigned within their organizations to assist with the Covid-19 response. Pharmaceutical manufacturers should reach out to customers that review drugs via a P&T committee and inquire as to how any upcoming reviews may be impacted. Manufacturers may expect some delays or disruptions in P&T schedules, particularly in states that have been hit hard by Covid-19. There may also be an opportunity for manufacturers to provide disease-landscape information to health plan or PBM customers that may have lost a knowledgeable member of their P&T team to the Covid-19 response.
Virtual meetings are becoming the norm beyond just the P&T process. All respondents across PBMs, IDNs, SPs, and health plans noted that meetings with pharmaceutical manufacturers had gone virtual. In addition to the typical high-priority information from manufacturers like product launches and rebate contracts, all stakeholders were interested in any information manufacturers had on potential disruption to manufacturing of product or the supply chain. PBM and IDN respondents noted an interest in whether a manufacturer’s product(s) were being tested as a potential treatment for Covid-19, since that may portend potential hoarding or inappropriate utilization. A significant drop off in manufacturer correspondence was also noted by respondents across the spectrum. While some distancing from customers may be expected during the pandemic, manufacturers may be well advised to occasionally “check in” via email to see if access stakeholders need any information or support.
Claims data trends
Health plan respondents were beginning to notice changes in medical claims. Claims for emergency department and urgent care visits related to upper respiratory issues had increased. However, claims for elective procedures and chronic care appointments had begun to decline. Due to the delay in medical claims, the trends noted here could be expected to accelerate as the pandemic continues. On the pharmacy side, both PBMs and health plans saw a surge in prescriptions, particularly 90-day fills, as patients attempted to stock up in anticipation of supply chain disruption. Health plans and PBMs were responding by loosening restrictions like refill-too-soon blocks in order to accommodate patients, despite a concern that short-term costs would rise. PBMs were also exploring implementing programs to limit access to medications suspected of being helpful for Covid-19, like hydroxychloroquine, in order to prevent hoarding.
The trends in claims data were felt on the front lines of both IDNs and SPs. IDNs noted that hospital census was down, as patients avoided all but the most essential healthcare. Specialists at IDNs were experiencing a marked decline in the “level of service,” as more comprehensive appointments gave way to quick touchpoints in an effort to minimize a patient’s time at a healthcare center. These changes had IDNs beginning to consider making difficult decisions like furloughing employees, and, in some cases, reassigning staff including having outpatient providers begin rounding on inpatients. At specialty pharmacies, prescription volume was steady but expected to decline, as fewer patients having doctor appointments meant fewer patients being diagnosed with new diseases. One specialty pharmacy noted that patients on immunosuppressive medications, including drugs for conditions like rheumatoid arthritis, were inquiring as to whether continuing such a medication was safe during the pandemic or if they should be switched to a less immunosuppressive alternative.
Perhaps one of the most alarming consequences of the pandemic is that the changes made to accommodate its effects may be resulting in the worsening of chronic conditions. IDN respondents stated that while hospital census was down, those patients that did come to the hospital for non–Covid-19 diagnoses were considerably sicker than the same patient type before the pandemic. This may indicate that patients with chronic conditions like COPD or heart failure that are decompensating are not going into the hospital until the last moment. The decrease in claims for chronic care appointments noted by health plans and the cancelled/delayed appointments mentioned by IDNs could be translating into worsening chronic conditions and sicker patients. This trend may be expected but it is no less alarming. Pharmaceutical manufacturers may want to communicate with customers at IDNs and health plans to understand if there are trends in decreasing chronic care and whether alternative ways of engaging patients are being undertaken. Resources on the implications of worsening disease from a patient health and cost perspective may be useful.
The decrease in chronic care is not necessarily due to a lack of access stakeholder engagement. IDN respondents stated that telehealth and virtual visit demand was surging, and providers were doing their best to accommodate, although not all were fully prepared. Chronic care appointments were, when possible, being transitioned to virtual appointments. A specialty pharmacy respondent stated they had even begun inspecting patients’ port and PICC lines via video conference. Health plans were responding by increasing coverage for telemedicine, while also noting an increase in demand for remote monitoring devices for conditions like heart disease and diabetes.
IDNs validated health plan respondent statements by highlighting that coverage for telemedicine was strong. The surge in telemedicine may be a lasting legacy of the pandemic. For pharmaceutical manufacturers, it will be imperative to understand how care is delivered via telemedicine and what this means for patient education about pharmaceuticals. Manufacturers may wish to prepare materials that are easily sent via email or displayed on a video conference. In addition, helping providers develop optimal ways to message on a drug’s safety and efficacy via a phone call may be valuable.
Many of the findings in our research have been validated by other sources. Preparations by relevant healthcare organizations are already being made for an expected surge in chronic care needs when Covid-19 is over.  Hospitals in some parts of the country have announced the furloughing of workers and reduction in salaries, as the lack of elective procedures and chronic care visits cuts into health system revenue.  Telehealth is indeed exploding in demand and may have a lasting effect on how care is delivered for years to come.  How long the pandemic lasts, and whether it wanes and then returns, will further determine future changes in the healthcare landscape.
Pharmaceutical manufacturers should have both a short- and long-term approach for addressing changes brought about by Covid-19. In the short term, ensuring appropriate drug supply and informing access stakeholders of any risks to a drug’s supply chain is important. Engagement with payers and IDNs on the potential implications of delayed chronic care may also help these entities better develop plans to address a chronic care bubble that may burst, post Covid-19. Manufacturers should also ensure their field teams are set up with appropriate technology to allow virtual engagement with customers. Longer term, manufacturers can expect that more care will shift to a virtual setting, and even some meetings and processes that customers previously did live may end up staying virtual. Pharmaceutical manufacturers should be prepared to deliver the value proposition of their drug(s) in this new virtual environment, to stay ahead in an ever-changing healthcare world.
1. STAT. With Covid-19 delaying routine care, chronic disease startups brace for a slew of complications. April 14, 2020. Available at: https://www.statnews.com/2020/04/14/with-covid-19-delaying-routine-care-chronic-disease-startups-brace-for-a-slew-of-complications/
2. Becker Hospital Review. 227 hospitals furloughing workers in response to COVID-19. April 7, 2020. Available at: https://www.beckershospitalreview.com/finance/49-hospitals-furloughing-workers-in-response-to-covid-19.html
3. White House. Deregulation Sparks Dramatic Telehealth Increase During the COVID-19 Response. April 28, 2020. Available at: https://www.whitehouse.gov/articles/deregulation-sparks-dramatic-telehealth-increase-covid-19-response/
About the author
Jeremy Schafer, PharmD, MBA is SVP, Access Experience Team at PRECISIONvalue. Jeremy leads a team of approximately 20 former payer and health system decision makers that help life science companies optimize their market access strategy. Prior to Precision, Jeremy held leadership roles in managed care at one of the nation’s largest PBMs.