About 58% of payers had at least one outcomes-based contract with a pharmacy benefit manager for prescription drugs in 2022, according to a survey published last week.
In an outcomes-based contract, prescription drug reimbursement is based on the outcomes achieved for the patient. These contracts represent a shift to value-based care.
Avalere Health, a healthcare business consulting firm, published the survey. The company conducted it online from February 14 to February 20 and received responses from 46 health plans. This is the fifth year the company has conducted the survey.
Of the payers that had at least one outcomes-based contract, more than 35% had more than 10 outcomes-based contracts in 2022. Another 10% of payers had five to 10 contracts, and a little over 10% had two to five contracts. About 15% had no contracts, but were in negotiations for one or more. Less than 10% had no contracts and were not planning on taking any on.
In addition, the survey found that of the respondents who had at least one outcomes-based contract in 2022, the top therapeutic areas the contracts were used for were oncology, cardiology and endocrinology. The therapeutic areas with the lowest amount of outcomes-based contracts were infectious disease, pulmonology and rheumatology.
Respondents also said that they’re using outcomes-based contracts for “mostly new products, but some existing products.” This shows “growing interest among stakeholders to align payment with clinical benefit, particularly for new products that have limited real-world clinical benefit.”
A Deep-dive Into Specialty Pharma
A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.
A majority of health plans with at least one outcomes-based contract, or 74%, said that they prefer contracts with both claims-based and clinical outcomes. That said, 53% of the health plans said they don’t think claims-based outcomes are a great way to measure clinical benefit.
“Claims-based measures are typically easier to track because they leverage information that plans and PBMs are already gathering, rather than clinical outcomes that may need to be tracked specifically for an [outcomes-based contract],” the report said. “Clinical measures can be more difficult to track if they require new data infrastructure and pose an additional administrative burden on providers and other stakeholders. Therefore, while clinical outcomes may better reflect clinical benefit, claims-based outcomes are more practical. … alignment among stakeholders on appropriate metrics of value that are also meaningful measures of clinical benefit is among the barriers to value-based care.”
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