Value-Based Contracting in Commercial Insurance. Risk-sharing agreements, also referred to outcomes-based or value-based contracting, are an underutilized but slowly growing type of payment model that brings together health care payers and pharmaceutical manufacturers to provide drugs to patients. Under risk-sharing agreements, pharmaceutical manufacturers and payers engage in an agreement that attaches financial and clinical outcomes directly to a product or service.
While risk-sharing agreements are more frequent in Europe and with the Centers for Medicare & Medicaid Services (CMS), there is only a small number of announced contracts in the U.S. commercial insurance market. Access Market Intelligence, through discussions with industry observers and participants, found that while both parties may be willing, developing a risk-sharing agreement is more difficult to complete.
In AMI’s report, Value-Based Contracting in Commercial Insurance, we reviewed publicly-available information to present background on risk-sharing and insight into risk-sharing agreements from a payer’s and manufacturer’s perspective.
Cigna – Crestor
AstraZeneca and Cigna intended to use predictive risk modeling to assess a patient’s overall health condition in order to give that person the appropriate cholesterol-lowering medication. The predictive modeling identified patients who were most likely to benefit from the treatment that Crestor provides.
For Cigna patients who were at increased risk for atherosclerotic cardiovascular disease and needed to aggressively manage their low-density lipoprotein cholesterol (LDL-C), Crestor was to be prescribed and filled without requiring prior authorization.
Cigna said that the move would help reduce out-of-pocket costs to the consumer. It is a more effective way to manage prescription drug costs for employers and customers by making it easier for higher-risk patients to obtain Crestor more quickly while still using generics where they are a viable alternative.
Patients identified as high risk could refill prescriptions with Cigna without prior authorization. The arrangement helped Cigna reduces costs, and save the administrative burden of prior authorizations.
Merck – Januvia/Janumet
Aetna entered into a value-based agreement with Merck for the type 2 diabetes medications Januvia® (sitagliptin) and Janumet® (sitagliptin plus metformin).
Merck’s rebates on Januvia and Janumet were based in part on those products’ contributions to helping Aetna’s commercial member population with type 2 diabetes achieve or maintain treatment objectives.
Merck said the decision to use treatment intensification as a measure for determining rebate value could be more straightforward in terms of the data collection requirements versus measuring an outcome like HbA1C.
For Januvia, the arrangement could provide a boost in the face of new launches in the GLP-1 and SGLT2 drug classes. The pact followed a performance-based partnership between Eli Lilly and Harvard Pilgrim for the weekly GLP-1 med Trulicity. The agreement with Aetna represented the first time the company has used treatment intensification for a value-based reimbursement agreement.