Risk-Sharing, Outcomes-Based Contracting Can Increase Accountability in Healthcare

Minneapolis—As the healthcare industry continues to evolve, risk-sharing programs and outcomes-based contracting are placing an increased emphasis on accountability. These concepts were discussed during a contemporary issues session at the AMCP meeting titled Outcomes-Based Contracting Driving Accountability. During the session, Joshua Cohen, PhD, a senior research fellow at the Tufts Center for the Study of Drug Development, Boston, Massachusetts, discussed the reasons for risk-sharing, how it is related to value, and its future. According to Dr. Cohen, risk-sharing has developed due to the rising costs of biopharmaceuticals, especially in the specialty medication market. However, patients still want access to these medications despite the costs and uncertain or marginal outcomes associated with some biologics. Risk-sharing is one way that a payer and drug maker can reach an agreement about a product’s price or revenue based on its future performance in a real-world setting. In such agreements, the risk to the payer is an additional cost for a product that may not have much clinical value or cost-effectiveness, while the risk to the drug maker is reduced revenue or discontinued reimbursement for the medication, Dr. Cohen said. Pay-for-performance agreements are contingent on patient outcomes or responses. According to Dr. Cohen, if the patient response is lacking, money is either returned or prices may be reduced. In coverage with evidence development, the agreement is contingent on outcomes or patient responses as well; however, if the outcomes are lacking, there is a risk that reimbursement could be discontinued. In the United Kingdom, the National Institute for Health and Clinical Excellence is leading the way in risk-sharing; however, the closed administrative, data, and outcome tracking systems in the single-payer system are not as feasible in the United States, where a decentralized healthcare system exists. In the United States, some private payers have begun to experiment with risk-sharing. For example, in 2009 sanofi-aventis and Procter & Gamble agreed to reimburse Health Alliance for the costs of treating fractures for patients who received Actonel. However, Dr. Cohen said risk-sharing agreements still need to evolve to fit the healthcare system in the United States and said this might be done through biomarker-linked reimbursement deals or value-based insurance design. Also at the session, Cyndy Nayer, the cofounder and CEO of the Center for Health Value Innovation (CHVI), St. Louis, Missouri, spoke about outcomes-based contracting and its focus on accountability. According to Ms. Nayer, the CHVI has defined a framework for outcomes-based contracting that focuses on engagement and accountability by aligning incentives and paying for outcomes. Outcomes-based contracting and value-based benefit designs can be used to improve overall health and employee healthcare benefits. By investing in healthcare, employers can increase productivity gains, increase employee work days, and achieve company savings. For example, CIGNA and Merck joined in an outcomes-based contract to help customers better manage their diabetes. According to Ms. Nayer, this joint effort helped improve customer blood sugar levels by 5%. In addition, those who actively participated in CIGNA’s diabetes support program were more likely to control their blood sugar than those who did not participate. The effort also was beneficial to the company’s bottom line, and, according to Ms. Nayer, if customers properly take their diabetes medications the company could save up to $8000 per person. In an effort to understand more about companies that have used value-based designs, the CHVI also conducted a survey with >175 companies that had value-based designs in place for ≥2 years. They found that 55% of those surveyed wished they had employees engaged sooner in the process and 45% would have used more effective means of gathering data. Outcomes-based contracting can help improve benefit design to encourage engagement and accountability. To be successful, according to Ms. Nayer, outcomes-based contracts need to align incentives between the health plan or plan sponsor and the manufacturer or service organization. The third speaker at the session was Laurie Amirpoor, PharmD, staff vice president, clinical program policy, WellPoint, Inc, Indianapolis, Indiana. She focused her remarks on the effects of value-based contracting on patient medication compliance. Dr. Amirpoor began by outlining the benefits of a value-based contract, noting that in a value-based benefit design, when the member is involved in a disease state management program for a chronic condition (eg, asthma, chronic obstructive pulmonary disease, coronary artery disease, heart failure, and diabetes), the plan provides higher benefit levels and/or lower cost-sharing for preventive services and medications. She continued by describing a pharmacy coaching program conducted with city employees in a Midwest city. The program was designed to improve diabetic and hypertensive members’ knowledge of their disease, adherence rate for their medications, self-management of behaviors and lifestyle, and clinical and economic outcomes. Program participants received no-cost coaching visits for diabetes and hypertension control. Copayments for diabetes, hypertension, and cholesterol medications were waived for all program participants. Medication adherence increased significantly for antihypertensive, statin, antidiabetic, and antidyslipidemic medication classes for program participants. In addition, there was an observed increased use of beta-blockers, combination therapies in participants with heart disease, and a similar observed increased use of metformin and statin therapies in patients in the diabetes program. Clinical outcomes also improved: for patients with heart disease, there was improvement from baseline to postindex seen on all clinical measures; for those in the diabetes program, there was improvement from baseline to postindex in all clinical measures with the exception of high-density lipoprotein cholesterol. In conclusion, Dr. Amirpoor stressed that an approach to value-based benefit design should be determined by outcomes and medical evidence. She said it creates a “partnership in healthcare” that can “engage members to participate in their healthcare, engage employers to help their associates have a healthier lifestyle and improve productivity, and engage providers to participate in providing quality care and help patients reduce their medical expenditures.”