It all sounds good in theory. The real question is how to apply it in the real world. To answer this question, here is an example of how advanced prescriptive preaching and analysis could be used to lead the implementation and follow-up of a results-based contract for a drug to assist patients/members who were at risk of heart risk (CHF). Payers have shown unease in investing in skills for results-based contracts because they are still considered new and unproven, Longuet said. The follow-up of hospitalizations, blood tests and remissions imposes great challenges on them. The FDA`s accelerated approval procedures, which facilitate the approval of drugs with substantial evidence of efficacy from the results of Phase 2 clinical trials, encourage pharmaceutical manufacturers to develop drugs for orphan indications. Although patients have accelerated access to orphan drugs, payers have little notice to include the cost of drugs in their budget.9 “This is due to the results and savings you can offer, and simply to a better understanding of the results – when patients react when they are not and why,” said Medicine Foundation CEO Cindy Perettie, in an interview with the J.P. Morgan conference. Combine all this with the operation of a payer by setting premiums through predictable annual expenses, and it will be easy to understand why we are learning value-based contracts. Predictability for a payer is a key component of success, and value-based contracts can be unpredictable.
There is also uncertainty related to HHS`s proposed rule to exclude prescription pharmaceutical rebates that are paid by manufacturers to those responsible for Safe Harbor Pharmacy Services, in accordance with anti-kickback status. The interest of health plans and drug manufacturers in results-based agreements appears to be quite great, with at least 50 agreements publicly announced. But ordering activity has slowed down as executives on both sides take stock of their experiences in recent years, said Jay Jackson, a consultant at Avalere Health, which focuses on the pharmaceutical industry. The justification for these high-priced therapies is multiple. The treatment of complex diseases in smaller patient populations involves higher pharmaceutical costs due to increased development costs, increased therapeutic complexity and higher manufacturing costs.9 For example, the process of extracting a patient`s white blood cells requires several specialized resources and lasts more than 3 weeks compared to the relatively simple process of developing a single-drug drug. In the face of such spending, combined with bureaucratic control to reduce drug prices, it is not surprising that the pharmaceutical industry is trying to experiment with alternative pricing strategies to allow affordable access to its specialty medicines.