Variation in Autoimmune Payer Mix Drives Channel Strategy

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Variation in mix of payer coverage across autoimmune diseases highlights the need for manufacturers to assess patient payer mix to support channels of access.

Payer mix refers to the percentage of patients covered by different types of payers, including commercial insurance, government programs such as Medicare and Medicaid, uninsured individuals, and others. Understanding payer mix provides valuable insights into the coverage landscape, reimbursement differences, patient cost exposure, and relative need for patient support within the patient population for a given disease state or treatment. It is a dynamic factor that varies across disease states and can change over time and stages of the patient journey, influenced by shifts in reimbursement, coverage policies, and the demographic and risk factors of the patient population. 

Avalere analyzed four clinically complex autoimmune diseases associated with high need for care to assess potential variations in payer mix. The analysis focuses on specific disease states with varying clinical and patient demographic characteristics within a broader therapeutic area to determine differences in payer coverage mix. The analysis revealed distinct differences between the types of payers who cover patients across disease states, highlighting the need for tailored access channel strategies. The differences in the payer mixes demonstrate the primary payer stakeholders for patient access will be different across treatments, even within the same therapeutic area. Manufacturers that understand payer mix for the indicated populations for their treatments can more effectively navigate the complex healthcare landscape to optimize access for patients. 

Study Findings 

Avalere studied four distinct patient populations with specific autoimmune diseases, delineated as Populations A through D. 

Table 1: Patient Population Demographics 

Patient Population Through On-Type of Disease  Percentage of Patients Under 65 Years Old  Percentage of Female Patients
A Rare chronic autoimmune disease  41%  53%
B Rare chronic autoimmune disease  86% 80%
C Secondary autoimmune disease  90% 83%
D Autoimmune disease  86% 64%
US Overall N/A 83% 51%

Avalere found that among patients with a diagnosis of a rare chronic autoimmune disease (Population A) where over half of the population was over 65 years old, 63% of the patients received coverage through Medicare, compared to the national distribution of 19% (source: Population B consisted of patients with another rare chronic autoimmune disease that is more common among women (80% of patients) and has a higher portion of patients under 65 years old (86%); these patients were also more likely to be covered by Medicare than the average patients, with 32% of patients receiving Medicare coverage. Similarly, Population C, patients with secondary autoimmune disease, which is more skewed toward women (83%) and has a higher portion of patients under 65 years old (90%), had a slightly lower portion of patients receiving Medicare coverage (29%), but still substantially higher than the overall US population. The fourth population (D) comprised of patients with an autoimmune disease with an age distribution closely matching that of the overall US population, while the gender distribution was 64% female. Among these patients, only 16% of patients were covered by Medicare.  

Figure 1. Payer Mix of Analyzed Autoimmune Diseases 

Key Considerations

These results indicate that the composition of payer mix is affected by multiple factors (e.g., age, burden of disease, risk factors) that vary by disease state. This underscores the significance of considering demographic, clinical, and financial burden factors when evaluating for specific diseases.

Payer mix can have a profound impact on access channels for patients, as it affects which providers and facilities are available, the administrative requirements patients must navigate, degree of financial burden, and the extent of coverage for specific services. A thorough understanding of the payer mix allows manufacturers to proactively address potential access challenges by collaborating with distribution channels that align best with the patients’ needs. Manufacturers can also tailor their reimbursement strategies based on different payer types and be better positioned to adapt to evolving policy changes, such as upcoming drug pricing policy changes introduced by the Inflation Reduction Act (IRA) that will have far-reaching effects for all stakeholders, varying based on product-specific payer mix. Knowledge of the payer mix further equips manufacturers to make informed decisions regarding the allocation of resources for patient support programs, ensuring that patients can have adequate access in the healthcare market.

To learn more about how Avalere’s experts can help your organization understand your patient population’s payer mix and support your access strategies, connect with us.


Avalere performed this analysis using 100% Medicare Fee-for-Service (FFS) claims, accessed by Avalere via a research collaboration with Inovalon, Inc., and governed by a research-focused Center for Medicare & Medicaid Services data use agreement. This includes the 100% sample of Medicare Part A and Part B Medicare FFS claims data and the 100% sample of Part D prescription drug event data for all Part D plans (including Medicare Advantage Part D plans). In addition, Avalere used data from Inovalon’s proprietary “Medical Outcomes Research for Effectiveness and Economics” (MORE2) Registry® (2021-2023), accessed by Avalere via an Agreement with Inovalon, Inc.

The Inovalon MORE2 Registry® is a real-world database that is inclusive of medical and pharmacy claims sourced by over 140 health plans and statistically de-identified. The MORE2 Registry® contains all major US payer lines of business including commercial (42% of market), Medicare Advantage (25% of market), and Managed Medicaid (69% percent of market).

Webinar | A Closer Look at Patient Support On June 6 at 2 PM ET, Avalere experts will explore how potential implications of the Inflation Reduction Act (IRA)’s out-of-pocket cap, in addition to other key regulatory and policy activities shaping benefit design and patient cost-share (e.g., EHB), could impact patient commercial and foundation assistance. Learn More
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