Bottom Line? |
Overall IHS access control and opportunity is more driven by site of care and less contingent on payer. |
Indian Health Service (IHS), which provides health care services to the American Indian/Alaska Native (AI/AN) communities in the United States, is frequently described as fragmented. Because the exact details of how this market segment functions feels complicated and opaque, it can seem like evaluating the potential opportunity is exceptionally difficult. However, the characterization of a fragmented health system is inaccurate when the overriding goal of pharmaceutical manufacturers is properly framed: providing the right product to the right patient in the right moment of care. Through that prism, a simple shift in how to evaluate and approach the market crystalizes the opportunity in a way that pharmaceutical manufacturers can make active decisions on direct engagement and resource allocation.
Members of the AI/AN communities have more payer options available to them for healthcare expenses. Some AI/AN peoples hold private commercial insurance available through their employer while others may qualify for Medicare and Medicaid programs available to the general population. However, what is unique for AI/AN peoples are that they may be able to subscribe to a private tribal health plan. Finally, IHS, itself, can pay for healthcare expenses as the payer of last resort.
When beginning the analysis of this market segment, pharmaceutical manufacturers must rejig their point of view and initially focus on potential patient population scoping. Understanding subsequent alignment between available resources based on this analysis to IHS (Federal and tribal) points-of-care locations will answer many questions on whether or not to continue with additional strategy formation.
Because AI/AN members are entitled to care at IHS facilities and, when eligible through tribal affiliation, at tribal facilities, it is these two types of sites that should be evaluated for direct outreach. Access to IHS Federal facilities is most similarly compared to a Department of Veterans Affairs (VA) Veterans Affairs Medical Center (VAMC). These facilities fall under the purview of a regional authority – called an Area in IHS and VISN in VA. Similar to the VA, IHS facilities are managed by a Federal Agency and are focused on serving a particular population. Procedures to visit a IHS Federal facility are comparable to the procedures to visit a VA facility. Tribal owned facilities, however, should be approached most similarly to their counterparts in the commercial marketplace.
Since IHS is a payer of last resort, a pharmaceutical manufacturer’s traditional reimbursement strategy and efforts with commercial payers and Medicare/Medicaid will automatically cover AI/AN persons regardless of point-of-care. IHS Federal sites utilize a basic national formulary with local formulary additions both frequent and common – which, again, highlights the importance of proper site targeting. IHS Federal is generally leveraging the Federal Supply Schedule (FSS) contracts managed by the Department of Veterans Affairs (VA) as well as the VA National Contracts with distribution for both occurring through the VA Prime Vendor. This means if a product is available through the VA FSS, then IHS can also easily order that product. IHS Federal may have supplemental contracts in order to achieve better terms, more favorable pricing for specific products, or access products not listed in the VA FSS; however, this scenario is less common.
The moment when "payer" has an important impact is when an individual is utilizing their tribal health plan. Tribal health plans can have their own formularies and inclusion on those formularies may require additional efforts on the part of the pharmaceutical manufacturer to achieve formulary status. The importance of approaching individual tribal health plans is dependent on the product and its potential utilization within that tribe.
Is reimbursement in the AI/AN for a pharmaceutical drug product fragmented? Yes. Is the market itself fragmented by geographic location, or population demographics? No. Because the size of the population served by IHS is smaller than that of VA, pharmaceutical manufacturers should not automatically assume IHS inclusion in its outreach strategy but rather evaluate the potential for each of its products separately to determine potential ROI of direct outreach with a focus on patient scoping.