After the 10 to 15 years and roughly $1 billion that Life Sciences teams spend developing a new therapy, its commercial success or failure will be determined largely by a group of health plans, pharmacy benefit managers, and the Centers for Medicare & Medicaid Services (CMS), which will set the parameters for if, when, and how it is covered. This stark reality is why Commercial, Market Access, and Health Economics and Outcomes Research (HEOR) teams invest billions each year researching the complex web of formularies, value-based benefit designs, and individual coverage types that govern reimbursement. 

At the crux of this research is proving that a new therapy drives better outcomes and lower costs than the current standard of care. While Life Sciences teams have made enormous strides in using real-world data (RWD) to track individual patient journeys and generate the evidence necessary to influence coverage decisions, the ability to track and understand the impact of those decisions is still extremely difficult. Without it, teams struggle to expand market access, drive therapy adoption, and capture a therapy’s true value and return on investment.

Known Unknowns
The complexity of the payer marketplace makes tracking payer coverage extremely complicated. Formulary and policy coverage is determined by a complex calculus that includes variables like coverage tiers, prior authorization details, and quantity limits; moreover, patients are often dual-eligible, change insurance providers, or have different coverage for medical vs. prescription care — creating a host of data continuity challenges. 

Historically, teams have attempted to address these issues by manually stitching together a mix of claims, formulary, and enrolled lives data — all of which come from different vendors and require bridge files and data mapping just to get the data to a place where it can be analyzed and visualized.

Unfortunately, this costly and time-consuming approach still delivers only a guesstimate of the payer market landscape. 

The Root of the Problem: Claims Data
Until now, pharma has had to rely on administrative claims data to obtain payer insights. This is problematic for many reasons:

• Incorrect insurance channel. Claims do not always capture the true insurer. For example, a claim may characterize a payer simply as “commercial” when, in fact, it is Medicare or Medicaid coverage being provided by a commercial carrier.  
• Wrong entity captured as the payer. Claims data often incorrectly categorizes the pharmacy benefit manager as the payer. 
• Multiple payers existing in claims data. A patient may have events that tie to multiple payers in a given time span, making it difficult to ascertain specific coverage accurately. 
• High rates of claims noting “unidentified payer.” Claims data often contains missing or incomplete data, including payer information, which results in a significant percentage of claims being categorized as “unidentified payer.” 

The Key: A Complete, Patient-Level View of Enrollment
Komodo Patient Insurance (KPI) addresses this fragmented process and incomplete view with a “centralized payer spine” that is built on patient-level enrollment data — the source of truth in payer coverage and thus the key to resolving missing payer insights and untangling conflicting information. With its breadth of data, Komodo is able to link claims, coverage, and patient-level enrollment data quickly and efficiently, delivering a whole new level of accuracy and granular clarity.  

As a result, Commercial, Market Access, and HEOR teams are now able to track the complete longitudinal patient journey across multiple data sources. They can keep tabs on the same patient as they move throughout the healthcare system, consult with specialists, change insurance providers, etc. 

Importantly, the previous goal of understanding each payer’s impact based on lives (size of the member population) evolves to an insight of greater value: the size of the target patient population within those covered lives and across specific geographic areas. In turn, teams can measure the effectiveness of payer contracting and pull-through.

Unlocking the Power of a Complete Patient View
The central thesis behind KPI is the same one that has guided everything we do at Komodo Health. By putting the patient first, breaking down the legacy silos, and removing unnecessary hurdles that prevent a true understanding of that individual patient journey, we’re making it possible to better assess and reduce the burden of disease. Perhaps nowhere in the overly complicated world of healthcare data is that focus more important than in understanding the inner workings of the payer market.   

By integrating these once-disparate datasets into a single platform that uses powerful analytics tools designed specifically for market access analysis, Komodo is transforming how Life Sciences teams think about what’s possible. 

Learn more about leveraging KPI for your commercial and market access initiatives by watching our webinar recording, “Komodo Patient Insurance: A Reimagined Approach to Payer Analytics.” If you’d like to schedule a demo, just let us know.