Roma Maksymowych, MPA

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If healthcare is to usher in the age of value-based care, health insurers are going to need plenty of data.

Outcomes-based contracting is among the most significant paths to reach this new dynamic. The phrase refers to arrangements in which a pharma manufacturer is obligated to issue a refund or rebate to a payer, depending on how well the therapy performs in a real-world population. The goals of these contracts are to help control high-cost drug spending and provide the best patient outcomes. For example, Harvard Pilgrim Health Care and Spark Therapeutics entered into a contract for a one-time gene therapy treatment, Luxturna, for retinal dystrophy, which can cost up to $850,000. If patient treatment on Luxturna failed and did not produce the clinical outcomes expected, then Harvard Pilgrim would receive a rebate from Spark Therapeutics.

There is the potential for these outcomes-based contracts between pharma and payers to have a positive impact on the healthcare system and provide more value-based care. However, questions remain on their effectiveness, presenting an opportunity to gain greater insights from payers on the perceived value of these contracts. As a result, 

 (HRA®) recently conducted more in-depth research to gain further payer perspectives on these outcomes-based contracts.

The original research by HRA® involved surveying various key players in the payer space who had direct knowledge about outcomes-based contracts, including pharmacy directors and managers of pharmacy contracts and value-based solutions from a variety of national and regional health plans. All reported being very familiar with the concept of outcomes-based contracts between a pharmaceutical company and a payer organization, and all currently reported they had at least one of these contracts in place.

For these outcomes-based contracts to be successful, data are key. Payers often mentioned having access to enough data and the correct data to effectively and accurately measure the outcomes is essential to making these contracts between pharma and payers a success. Over half of the payers surveyed said they felt they had enough data to successfully develop an outcomes-based program with a pharma company. About a third felt they did not, which is likely one main reason for any hesitation into entering into these types of outcomes-based contracts.

As far as the actual data needed for the success of these outcomes-based programs, almost half of payers surveyed said their own data are the most essential. However, they also advocated for access to electronic medical records data from providers to give a more complete clinical picture. And interestingly, less than 10% of payers said data from a pharmaceutical company, such as clinical trial data, would be the most essential data to make an outcomes-based contract a success.

Aside from getting the necessary data, access to the correct analytics tool to make sense of the data is also key. Payers were asked if having a predictive analytics tool that forecasts patient outcomes on a specific drug would increase the likelihood of a managed care organization to negotiate an outcomes-based contract with a pharmaceutical company. The result: 82% said such a tool will make them more likely to engage pharma to negotiate outcomes-based contracts.

In the move toward more value-based care in the US healthcare system, the role of outcomes-based contracts between pharma and payers is becoming more and more important. As this HRA® research supports, the success of these contracts will rely heavily on the availability of good data and the tools necessary to make sense of the it.

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Roma Maksymowych, MPA

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Before Striking Outcome-Based Pharma Contracts, Payers Need Data