Is the drive to value-based care really accelerating? What can be done amidst all of the uncertainty? Expert shares insights from the J.P. Morgan 35th Annual Healthcare Conference.
Despite news breaking on the first steps toward the repeal of the Affordable Care Act (ACA) and President-elect Trump’s comments on pharmaceutical manufacturers and pricing, not all was doom and gloom at the J.P. Morgan 35th Annual Healthcare Conference 2017, January 9-12, in San Francisco. Here are a few to-dos and reasons for optimism for managed care executives that we learned during our time at one of the most significant healthcare business event of the year.
However slowly in some spaces, nearly every session I attended featured a focus on value-based care. No longer a dull hum in the background, I sensed a vibrancy in discussions and initiatives designed to accelerate the drive to value-based care at J.P. Morgan 2017 that had not existing in previous years.
In its simplest terms, we define value as outcomes divided by cost. Winning organizations improve outcomes while reducing costs at the same time. And they should be prepared to prove it.
Express Scripts launched its Diabetes Care Value Program last year, the fifth in a series including hepatitis, inflammatory conditions, cholesterol and oncology care. According the PBM, “The Diabetes Care Value Program is projected to boost the average medication adherence rate for enrolled patients by 5%, reducing downstream health complications and healthcare costs. Currently, $4,690 per diabetes patient is spent each year on medical expenses that could have been avoided if patients had taken their diabetes medications as prescribed.”
The efficacy of the program in real-world conditions will take time to measure, but it is a step in the right direction. We know well the importance of medication adherence to the value equation. In October, preliminary results of a Curant Health study with Johns Hopkins indicated enhanced medication therapy management improves adherence by 30% over the standard of care for patients with inflammatory bowel disease (IBD). Multiple colleagues with whom we met reacted with near amazement when we shared this data with them.
We heard many more questions than answers within the healthcare industry at J.P. Morgan 2017. There were fewer big announcements at the show compared to any year in recent memory. The M&A guys were on the hunt for deals and not finding many at J.P. Morgan 2017. One notable exception was WellCare’s acquisition of Universal American. That aside, an uncertain tack on legislation and the pending status of the Aetna-Humana and Anthem-Cigna deals has most healthcare executives playing the wait and see game. This might be prudent with respect to big moves, but executives should not be lulled into complacence when there are immediately actionable, value-based to-dos.
1. Find your value-based partners. If you can find partners that improve value, your cost profile, HEDIS responsiveness, reduces readmission rates or improve adherence especially to specialty medications, wait and see does not apply. Find them. Engage them. Insist on value-based success in real-world situations, not just clinical trials. Real-world efficacy is going to become the gold standard in care, especially for pharmaceutical manufacturers.
Next: Align incentives
2. Start with the patient when aligning incentives. In likely the most entertaining session at J.P. Morgan 2017, James Carville and Karl Rove generally agreed that whatever becomes of the ACA, whatever is next needs to start with the patient when aligning incentives. PBMs, pharma manufacturers and service providers sure do like to talk about patient centricity and we heard plenty of that kind of talk last week. I would encourage you to ask anyone that mentions it about what exactly it means to them. How do they define patient centricity? How long have they been “committed” to it? What metrics do they use to support their claims? Exactly how do they put the patient first in order to align the balance of the ecosystem including and especially prescribers, payers and pharma manufacturers?
The pharmacy community is grappling with the impact direct and indirect remuneration (DIR) fees are having on their businesses. Originally designed by CMS as a way to track manufacturer rebates applied to Part D medications and the overall impact on the Part D program, DIR fees have the potential to put some a large number of pharmacies out of business, even though the measurement metrics might be beyond their control. Too many pharmacies are currently being “graded” on things they simply cannot control, like disease state measurements on drugs they aren’t providing to the patient.
Diplomat CEO Phil Hagerman said, “Diplomat and the entire specialty pharmacy industry do not agree with how the practice has evolved and the broad expansion that has taken place in 2016. We don't feel that the way some of the PBMs are calculating these fees meet the goals, outcomes or spirit of CMS’ intentions.”
There are those who said at JP Morgan that DIR fees could be the demise of the independent specialty pharmacy moving toward health plans and /or PBM-owned specialty pharmacies. There is sure to be a great deal of discussion between PBMs, specialty pharmacy organizations and policy makers regarding DIR fees for the foreseeable future.
Marc O’Connor is chief operating officer for Curant Health. Curant Health provides medication management, patient support and pharmacy fulfillment services for patients nationwide.