Simplify sales season by arming yourself with facts – and focus – for what your customers need.
By Jim Poggi
If you have not yet been inundated with information pertaining to this year’s respiratory testing season, I would be very surprised. Last month, Repertoire took on a broad view of the products, the market and a world of things you need to know. Since influenza testing really took off around 2005 or 2006, respiratory testing has been moving and changing rapidly. Rapid group A strep tests first launched to the market in the 1980s, but the market for a portfolio of rapid diagnostic tests did not really become a reality until influenza took off around 2005 or 2006. From there, the proliferation of new tests and new technologies has been an absolute blur. In this column I am neither going to review the technology and its changes in detail, nor do I intend to relate the history of rapid respiratory testing. Instead, I plan to discuss respiratory pathogen and vaccine trends I expect to see this season and ask us to focus on how we will deliver clinical and economic value and to which customers.
Let’s start with a review of common respiratory pathogens, their incidence and likely trends this season. As you might expect, it is too early to see an early fall increase in hospitalizations and positive test results. But there has been a fair bit of noise in the market and the news on a few fronts.
Things to keep in mind
The latest COVID variant is EG.5 (sometimes referred to as Eris), an offshoot of the Omicron family. At press date it was the fastest growing COVID pathogen, accounting for about 17% of all new cases. The good news is that this strain does not appear to carry a greater morbidity or mortality threat than any other recent COVID variants. So, while we can be confident infection incidence due to this variant will rise, at this time it does not look like a major public health threat. We can be equally confident that new COVID variants will continue to emerge as the season progresses.
Pfizer, Moderna and Novavax are all producing vaccines that will be available this fall which are expected to be effective against this variant. It is too early to know exactly HOW effective, but these new vaccines are expected to be able to reduce hospitalizations and shorten duration of illness. All by itself, this should reduce the spread of COVID this season.
Current hospitalizations related to COVID are averaging 10,000 per week. For context, in their peaks in January 2021 and January 2022, they were 120,000 and 150,000 hospitalizations per week respectively. While it was not initially clear whether COVID would follow the seasonal pattern of other respiratory pathogens, it now appears that as it has declined from pandemic levels, it is showing every sign of becoming a seasonal pathogen, which will circulate concurrently with influenza, group A strep, RSV and others.
Influenza is also quiet as expected so far this year. Total reported tests are only about 26,000 per week, with less than 250 positive results as reported by the CDC. The dominant strains so far this year for flu A strains are H1N1 and H3N2, both of which have been prevalent in prior years. Flu A is somewhat more prevalent (58.8% to 41.2%) than flu B, which is typical of past seasons. We clearly expect the trend in infections and hospitalizations to sharply increase as the season progresses.
What about strep? Last season, strep peaked in February, with a 30% increase in cases compared to the prior year. This increase was the highest seen since 2017 perhaps due to relaxation of the isolation practices related to COVID in recent years. Clinicians are most likely to see children in the 4-8 age group with group A strep infections, followed by the 9-12 year old group. In a typical season, the infection rate varies from 5-8% in these groups. Despite the significant concerns about viral pathogens, group A strep can have the most devastating complications on future health including rheumatic heart disease. It is readily treatable with conventional antibiotics as long as it is diagnosed early. Delayed diagnosis can lead to serious complications later in life.
RSV has been in the news for a couple of important reasons. While its incidence does not mirror the higher rates of other respiratory pathogens, it is particularly serious in children under one year of age. For this reason, it is advisable to use the highest sensitivity and specificity tests available to assure the lowest possibility of a false negative result. Molecular assays as a group have significantly reduced the incidence of false negative results and have raised the reported incidence statistics of RSV infection in the U.S. and worldwide. In past years, the elderly population has not been discussed as an RSV risk group. That has changed this year as two different vaccines have been approved by the CDC for adults over the age of 60. This has drawn attention to the higher risk of morbidity and mortality the elder adult population faces especially with respiratory infections. It also appears to be driving interest in RSV infections for all age groups.
Overall vaccine forecast for the coming season indicates that adoption of the COVID vaccine is likely to remain low, despite news articles discussing the new EG.5 variant. Without compelling data to indicate otherwise, I expect flu vaccine adoption to mirror prior years, somewhere in the 150-190 million dose range. With RSV it is too early to tell. There is insufficient public concern at this time to cause me to believe there will be a lot of early adoption of the RSV vaccine. At this point, your best bet is to discuss what your customers are telling their patients and the response they are receiving. This grass roots information should indicate the direction of early adopters. Time will tell.
Customer focus: Despite the substantial amount of interest in home testing during the COVID pandemic, I expect home testing to fall back for several reasons. Private insurance is no longer required to provide home COVID tests at no charge, and stay at home and travel restrictions based on the public health emergency have been lifted. As a result, patients are returning to the doctor’s office. The trends are clear. In the second quarter of 2020, during the height of the pandemic, 69% of patient visits were virtual according to a Harvard Business Review article. In a CDC study tracking virtual visit trends, they note a fall off in virtual visits during 2020 from 35.8% in April to 30.2% in June. I do expect remote visits for respiratory illnesses especially to remain somewhat above base line levels prior to the pandemic. As a long-term trend, I expect virtual visits to continue to gain patient acceptance and market share. There are sound economic and patient care rationales for this shift. Infrastructure is now widely available to support this trend and IDNs in particular are supporting virtual visits actively. Mobility issues of the elder patient is also a compelling factor. While I am not sure what the trend line for acceptance will look like, it is not unreasonable to predict that virtual visits will match or surpass the number of in-office visits by the end of this decade.
Secure your position
Where does this leave the distribution account manager selling respiratory testing solutions? In my view, it means the savvy account manager will focus on securing his position with his current customers to support their in-office visits and patient testing first. Protect your current business first, and then look for new or re-captured office-based customers second. At the moment, focusing on the needs of offices providing direct patient care would seem to be where the respiratory testing needs are greatest. Selling EVERY solution in your impressive range of products and services to these customers is the recommended approach. Lab tests are key, but only one element of your impressive offerings. At the same time, the account manager should look for data on shifting visit trends using information from their home office, IDN sales team and key manufacturing partners.
The clinical story of lab tests continues to favor adoption of molecular assays from several viewpoints. While lateral flow assays can be fast, and readers of lateral flow assays improve performance and reading objectivity, molecular provides the greatest clinical performance regarding sensitivity and relative independence from the need for a very good swab. As the news and noise level around RSV continues to grow this season, you are likely to find a number of customers asking for advice on how to optimize performance of their RSV assay.
In my experience, specific customers reluctant to adopt earlier technology for RSV due to concerns about false negatives are far likelier to listen to the story of testing RSV using a molecular platform. For non-adopters of RSV tests, it pays to ask why and tailor your presentation along with your key lab manufacturers to explain how the improved technology assures better sensitivity and far fewer false negatives. Using this presentation as a starting point can lead to a broader discussion of the entire respiratory lab portfolio and overall medical surgical spend. It makes sense to use this approach to refresh your discussions with many of your customers as respiratory season approaches.
Another bright spot as this respiratory season approaches is that further reductions in PAMA reimbursement cuts to the Clinical Lab Fee Schedule are suspended. While the SALSA act remains in congressional committee, no further cuts in lab reimbursement have been imposed in 2023. So, in addition to clinical value, lab testing at the point of care continues to make sense from an economic viewpoint. While the future of the SALSA act remains uncertain, it would seem likely that some form of this legislation and protection of lab reimbursement from cuts that are believed to endanger access to care especially in rural areas is likely to pass congress ultimately.
In summary, as respiratory season prepares to unfold, we need to be prepared with facts at our disposal, open to the guidance and advice of both the home office and our key lab manufacturers and to remain focused on learning more about the concerns of our current customers in the face of the changing respiratory season landscape. Our customers have learned a great deal about prevention using previously available vaccines for influenza and pneumonia. The trend for new vaccines against pathogens including COVID and RSV continues. Physician offices are becoming more aware of the need to isolate patients likely to spread respiratory infections from the rest of their patients. And, as the number and quality of lab tests continues to increase, our value as consultants continues to grow also.
Be armed with the facts, focus on the right customers, listen carefully to what they must share and work closely with your key lab manufacturers this season. Preparation is the path to success as respiratory seasons continue to change from year to year.