Closing Gaps in Health Plan Performance with Stakeholder Collaboration

Closing Gaps in Health Plan Performance with Stakeholder Collaboration

Published in American Health & Drug Benefits, October 2015, Vol 8, No 7, Optimizing Rheumatoid Arthritis Therapy: Using Objective Measures of Disease Activity to Guide Treatment

F. Randy Vogenberg, PhD, RPh, Partner, Access Market Intelligence

Employers/Health Plans: For most commercial health plans and employer-sponsored health plans, immunology represents a significant area of healthcare spending. Rheumatoid arthritis (RA) is a common condition within that category, and continues to grow as the population ages and medical technology advances. Despite the improvements in understanding the disease and its underlying pathophysiology, much remains unknown.

Treatment strategies have emerged that work well and can reduce healthcare costs and improve the population’s health. As Dr Owens points out in his article,1 however, there are gaps in measuring RA and in the diagnostic tools available to assist clinicians in effectively managing the disease. In addition, clinicians embody a large gap between desired outcomes and real-world practice because they often do not follow clinical guideline recommendations. This dual set of gaps represents a challenge for purchasers of healthcare who increasingly seek year-over-year improvements in plan performance in both clinical and economic domains.

During the past several years, the National Employer Initiative on Biologic & Specialty Drugs has conducted an annual survey of employer plan sponsors that has shown a shift to a more balanced result in plan performance between economic and clinical parameters.2,3 The keys to achieving that result typically include the closing of gaps in plan execution, improving collaboration among healthcare providers, and ensuring consistency in the delivery of evidence-based medicine, including the appropriate use of biologic drugs.

Partnerships between multiple stakeholders are evolving in response to decreased reimbursement schemes that, in many cases, result in a need for drastic administrative expense reductions to offset income reductions. Collaborations, such as accountable care organizations, patient-centered medical homes, and various direct contracted relationships between healthcare vendors and employers, are demonstrating commercial health plan cost-savings that have the potential to benefit both the patient and the employer plan sponsor. Some of those collaborations also include shared or at-risk arrangements in the contracting strategy. Blue Cross Blue Shield plans, among others, have piloted and pioneered the expanded use of such contracts in a post–Affordable Care Act marketplace.

Patients/Providers: Through shared risk arrangements, the use of more effective measures of performance by all stakeholders aids in driving the desired change in the healthcare delivery system. Today the purchasers of healthcare include patients, because they are now part of the shared risk equation through a variety of high-deductible health plans. Expect increased interest in the results from clinical measures of performance that may be tied to a rapid increase in the use of biologic drugs during the next few years.

The increased use of high-deductible health plans by consumers and shared risk among clinical providers still requires an approach that addresses the emotional needs of patients who are in treatment programs. Although better methods of assessing RA are needed, so is closing the treatment decision gap among providers. Patients need support with their treatment programs to achieve optimal performance from the purchaser’s healthcare investment. Encouraging providers to deliver evidence-based healthcare to actively engaged patients can result in economic success for all stakeholders.

1. Owens GM. Optimizing rheumatoid arthritis therapy: using objective measures of disease activity to guide treatment. Am Health Drug Benefits. 2015;8(7):354-360.
2. Vogenberg FR, Larson C, Rehayem M, et al. Beyond the cost of biologics: employer survey reveals gap in understanding role of specialty pharmacy and benefit design. Am Health Drug Benefits. 2012;5(1):23-30.
3. Larson C, Vogenberg FR. Guiding employer management of specialty drugs. Am Health Drug Benefits. 2015;8(5):256-257.