How Biopharma Companies Can Optimize Field Reimbursement Models

According to Megan Wetzel, VP, product, access & affordability, CoverMyMeds, specialty drugs continue to account for a disproportionate share of US drug spending despite representing only a small percentage of prescriptions. Several key factors contribute to this imbalance, and chief among them are the complexity, cost, and specificity of specialty therapies.

Unlike traditional retail drugs, specialty medications are designed to treat serious, chronic, or rare conditions and often require specialized handling, monitoring, and administration. Many must be administered in clinical settings such as hospitals or physicians’ offices rather than through retail pharmacies. These requirements add layers of logistical and operational costs throughout the treatment process.

In 2024, specialty drugs represented 93% of all new US drug launches, reflecting the industry’s increasing focus on advanced, targeted therapies. This surge has been driven by massive R&D investment, with biopharma research spending exceeding $100 billion last year—a 44% increase over 2023. Much of this funding has been channeled into developing complex, high-value specialty treatments.

However, these therapies are inherently expensive to produce and often serve smaller patient populations, driving up per-patient costs. The personalized nature of these drugs, longer development timelines, and limited market competition further compound pricing challenges.

Adding to the pressure, demographic trends such as the rise in chronic disease and an aging population continue to increase demand for these medications. The U.S. population aged 65 and older is projected to reach 63 million this year, a 9% jump since 2022, and climb to 82 million by 2050.

Ultimately, Wetzel noted, the imbalance stems from the intricate science, individualized care, and high economic stakes behind specialty medicines, factors that will only grow more prominent as healthcare becomes increasingly specialized and patient-centric. She also dives into the role of field reimbursement managers in helping patients access specialty medications; considerations that should guide insourcing, outsourcing, or adopting a hybrid model for field reimbursement support; and much more

A transcript of her conversation with PC can be found below.

PC: What are the main considerations that should help guide organizations that are weighing whether to insource, outsource, or adopt a hybrid model for field reimbursement support?

Wetzel: It really comes down to flexibility and fit. I do think, to your point, it's dependent on that specific biopharma's needs. That specific biopharma’s circumstances depends on kind of what the in-house sales team currently looks like. What are they currently supporting? Do you have the resources that you need in-house to extend that education and support in the field? Is that something that you need from an outsourced vendor?

I think the key though is you really want to model that integrates well with the provider workflow, so thinking about how you can give those field teams the data that they need so that they are providing the most information that they can when they're in the field in those provider offices. I think some of those hybrid models are really gaining traction because you're seeing some of these typical sales teams then getting paired with these kind of data-focused field teams that are out there really educating about specific denial analysis or specific friction points, because they've got tools from some of these outsource vendors in this space.

I think it just comes down to a specific fit for that manufacturer and maybe that brand or that therapeutic area, if those sales teams are educated enough to have those conversations. Sometimes, they need that additional data that can come from an outsourced vendor. But ultimately, you want a model that fits however it's going to be easiest to get that patient on therapy, depending on what your coverage barriers may be and what your process barriers may be. The goal is to get that field team as educated as possible around those problems.