There is still considerable debate and experimentation as to how the proposed Accountable Care Organizations will be structured and function. It is also hard to understand how widespread it will be once implemented. What is known is that as healthcare reform begins to take shape, the push (with financial incentives) for accountability in delivering higher quality care at lower cost will drive a more coordinated approach to comprehensive healthcare for patients. As a result, hospitals and physicians are beginning to explore the best ways to work together to ensure that the quality of care they deliver will be accurately reflected in whatever measurements the government (CMS) decides to use for evaluation. ACOs will in theory be rewarded by sharing the cost savings resulting from keeping their enrolled populations healthy and treating their patients efficiently and effectively.
The comprehensive care expectations for Accountable Care Organizations are beyond the capabilities of most solo physician practices or even small groups. Also, hospitals will need to expand their roles to include better coordinated post hospitalization care to ensure patients continue their recovery without relapse and re-hospitalization. This integration of care approach is causing some private practice physicians to consider joining larger group practices and encouraging hospitals to reach out to employ and align with the best physicians in their geographic coverage areas.
So how will this affect pharmaceutical sales?
The first implication of Accountable Care Organizations is most likely going to be a further reduction in sales representative access to primary care physicians as they join larger, busier group practices or hospitals. Representative access to these physicians is likely to be governed by even more selective product recommendations and administrative policies developed by the Accountable Care Organization. The impact on physician time with patients and the potential for sales reps to influence expensive branded product use will also affect access decisions. If representatives can demonstrate value by favorably impacting quality of care or cost reductions, they will find physician access less challenging.
Adoption of best practices and formalizing treatment guidelines will mean physicians will be less autonomous in their prescribing practices. They will also have a financial vested interest in prescribing cost effective treatments, complying with formularies, and following recommended treatment guidelines established by the Accountable Care Organization. This will make it more difficult for pharmaceutical representatives to directly influence prescribing of products not supported by ACOs.
Electronic health records (a prerequisite for Accountable Care Organizations) will make the real world impact of drugs on provider quality of care and costs more readily available for evaluation. Electronic medical records and e-prescribing will also allow for managing and monitoring compliance with treatment guidelines. These assessments and compliance monitoring will leave less opportunity for random use of expensive branded products with marginal clinical benefit. Deviations from treatment guidelines will require justification and could result in reprimand or potentially expose physicians to financial penalties if repeated non-compliance results in increased costs without clinical benefit.
Companies with products that can demonstrate improvements in clinical outcomes (better than alternative treatment options) or reductions in overall healthcare costs will find a much more receptive institutional audience than they might have in the past. Companies armed with compelling data will be able to influence the inclusion of their products on formularies and in treatment guidelines. This is especially true for value-priced preventive medicines, vaccines, and companion diagnostics.
Sales representatives with new products or products that are not favorably received by the ACOs in their territories will be faced with the challenge of gaining acceptance. Unlike having to convince (selling) individual physicians to prescribe your product, formulary and treatment guideline recommendations will be determined by healthcare provider teams with therapeutic and cost benefit expertise. More importantly, electronic health records will provide these teams with easy to analyze comparative clinical outcomes and cost data from their own organizations, making it even more difficult for companies (and representatives) without comparable data to make their case. Collective expertise, real world data, and financial incentives for delivering good clinical outcomes at low cost will make for a hostile environment for companies and representatives who are not equally armed with expertise and real world therapeutic and cost benefit data.
On the other hand, if the Accountable Care Organizations feel a product can help them achieve their quality of care and cost savings goals, representatives may be enlisted to assist the ACO achieve its goals. Representatives could be encouraged to help educate physicians and other healthcare providers about the appropriate use of their product (within treatment guidelines). They might even be called on to assist with implementing adherence and compliance programs to make sure patients take their medications as directed. It might even get to a point where products are placed in treatment guidelines contingent on delivering the expected clinical outcomes and cost benefits. This would require representatives to understand the metrics for assessing their product performance and staying current with how their products are performing (clinical outcomes and cost savings) within that ACO.
Regardless of how the ACOs are structured or how they decide to operate, it will mean a completely different work environment for pharmaceutical sales representatives.