Three tools for successful risk-based pharma negotiations

The days of  biopharmaceutical manufacturers and payers operating in isolation are over. Trapped in the firestorm of prior authorizations, high-deductible plans and ultra-high-cost medications are the patients who need all the help they can get to not only access, but adhere to their therapies.

O'Connor

From the head-spinning blowback on PCSK9 inhibitor pricing to the ham-fisted Turing Pharmaceuticals Daraprim snafu, biopharmaceutical manufacturers can be assured that more pricing scrutiny is coming for all high-cost therapies. In the future, biopharmaceutical manufacturers will need to go “at risk” in some contracts--accepting lower prices or zero payment if high-cost therapies do not demonstrate their value where outcomes divided by costs create measurable, meaningful results.

Rather than just hammering down on drug pricing and laying out a list of programmatic demands on manufacturers, managed care executives can bring the following resources to smooth “at-risk” negotiations aligning all parties for value-based success.

Leverage or create programs that measure and improve adherence beyond MPR.

One key element manufacturers will seek in “at-risk” negotiations is programs that positively affect outcomes once the drug leaves the pharmacy. Medication possession ratio (MPR) alone is not a sufficient metric for therapy compliance. Metrics on accessibility, abandonment rates and adherence data beyond refill claims data are needed. Implementation and leveraging of programs that improve adherence, mitigate negative side effects, improve access and patient education will improve the likelihood a manufacturer will be receptive to some risk-sharing.

Related:Humana provider tools aid value-based care

AbbVie, manufacturer of Humira, uses their “Humira Ambassadors” program to affect positive outcomes for disease states aligned with Humira’s indications. The program provides supplemental education including appropriate injection techniques, access assistance (including copay assistance for some patients) and other support including medication reminders.

According to an AbbVie-sponsored study abstract published in the Journal of Managed Care and Specialty Pharmacy in April 2015, AbbVie’s Humira free Patient Support Program (PSP) had significantly lower 12-month medical cost by 23% associated with patients using PSP, 22% lower disease-related medical cost for PSP patients, and 10% lower total costs for patients enrolled in PSP program. According to the abstract, the sample included patients aged 18 years or older with a diagnosis of Crohn’s disease, ulcerative colitis, rheumatoid arthritis, psoriasis, psoriatic arthritis, or ankylosing spondylitis.

It would be reasonable for MCOs and other payers to approve payment for therapies with the assurance that the patient is committed to working with similar patient-support teams and programs. Patient-care coordinators also are an example of expanded care team resources proven to improve adherence and outcomes.

The takeaway: Just because prescriptions are being filled (the key element in MPR), that does not mean patients are actually taking their medications, or taking them properly. Patients need a greater level of support including regular contact with other members of the patient-care team (pharmacists are excellent resources for this) to remain adherent to their medication regimens. This is especially important once they start feeling better, in order to avoid abandonment and improve outcomes.

 

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