According to National Health Expenditure Data (published by CMS), prescription drug spending reached $333.4 billion in the year 2017 and by year 2027, is projected to reach $576.7 billion. Furthermore, the industry is witnessing unprecedented prices for new drugs and sharp hikes in prices for medicines that are currently in the market. This astronomical rise in drug prices and the overall expenditure on prescription drugs has pushed the total cost of Healthcare up, resulting an increase in participant’s contribution in the form of premiums / copays / deductibles, making innovation in the drug industry virtually impossible for few unfortunate ones. Other factors that challenge the current PBM business model are – stricter government regulation, the push towards outcome-based payment model, rise in demand and cost of specialty drugs, and a much-needed focus on consumerization.
With a collective push from government bodies and healthcare industry towards value-based pricing and outcome-based payment, the industry is adopting new age business / payment models like Accountable Care Organization, Bundled Payment, Provider Payment tied to performance / patient outcome and Evidence Based Medicine. PBMs are also changing – some of them have already set value-based prices / outcome-based payment for certain categories of medicine by getting into contracts with drug manufacturers. Under outcome-based models, volume-based contracts may become less popular and get replaced by contracts, where the reimbursements are based on the value being generated by the medicine.
Identification and measurement of the value generated by a medicine is critical. Few options are -
Impact of Value-based Contracts
With value-based contracts placed in the Pharmaceutical category, the world will move towards a better and more efficient health care system. Here are few pointers on how major stakeholders may get impacted under a value-based contract -
Payers / PBM -
Drug manufacturers -
Consumers -
Challenges with Value-based Contracts
Moving away from traditional volume-based contracts with drug manufacturers is easier said than done for PBMs and payers. Before getting into any value-based contract, there are few fundamental questions that PBMs / Payers and drug manufacturers must answer -
CitiusTech’s Perspective
Even though not many PBMs / Payers and drug manufacturers have engaged in outcome-based contract models, it might soon change. Since June 2016, Harvard Pilgrim Healthcare has signed numerous value-based contracts with pharmaceutical companies – namely AstraZeneca, Spark Therapeutics, Amgen, Eli Lilly & Company, Novartis for drugs that treat conditions such as asthma, chronic obstructive pulmonary disease (COPD), retinal dystrophy, LDL cholesterol, acute coronary disease, type II diabetes, rheumatoid arthritis, osteoporosis and heart failure.
Moreover, the Center for Medicare and Medicaid Services (CMS) and large players in the Health Plan industry such as Cigna, Aetna and United Health Group have announced outcome-based contracts with pharmaceutical companies in recent times.
To ensure such models deliver -
References -
https://www.harvardpilgrim.org/public/about-us/newsroom
https://www.unitedhealthgroup.com/newsroom/2017/0525optumlearninglab.html