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From Pathways to Pharmacy: Sharing Approaches to Value-Based Care
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December 22, 2018

From Pathways to Pharmacy: Sharing Approaches to Value-Based Care

Mary Caffrey
A new session at the Academy for Managed Care Pharmacy Nexus 2018 allowed for sharing ideas that have recently been put into practice.
Andrew Hertler, MD, FACP, presented a strategy for implementing a value-based clinical pathway in oncology, which he said is helping a Florida practice select high-value regimens that save payers money—without giving up margins that cost the practice.

The “buy and bill” method that historically sustained oncology practices is giving way to value-based strategies as the cost of treatments escalate. Physicians once were paid a percentage of the cost of the therapy, but payers now look for ways to encourage practices to embrace low-cost options while giving patients the best evidence-based medicine. As Hertler illustrated, in this system, a payer can reimbursement the practice the same amount by encouraging the practice to use a lower-cost treatment that works just as well—a biosimilar, for example. But the payer saves by spending less on the therapy itself.

How does the oncologist know what to select? It’s all built into clinical pathway software that gives the practice choices, Hertler said. In the sample he shared, the US Oncology–affiliated practice saved 14.4% on the average Medicare Advantage member medication cost, and received a $152,000 bonus. Goals were met or exceeded in most cancer types, except bladder cancer.

As has been found elsewhere, a champion is essential. “We had one physician leader,” Hertler said. “This would have been more difficult without him being willing to buy into this.”

Data and feedback are important as well. Doctors are “all above average,” and do not like being the outlier. When they first see they are, they tend to question the data before self-examination occurs. But eventually, it happens.

Maggie Alston, CHFP, of Milliman in New York, New York, offered advice on a pair of overlooked elements of value-based contracts: patient attribution and risk modeling. Defining these items upfront is extremely important, she said, yet they are often overlooked until partners are far along in the process. The ability to define the patient universe is so critical, she said, that an inability to do so may mean that some contracts simply can’t be done, if administrative burden is so high that the potential savings just are not there.

When setting out to start a contract process, Alston recommends getting many people involved—actuaries, data scientists—a diverse team is needed. “Be ready to think outside the box,” she said.

Patient attribution is important because it’s so directly tied to any contract that addresses adherence. Patients can stop taking drugs for many reasons, and there are so many ways to measure how patients take drugs. Knowing who the patients are is key. “Medicaid patients are much sicker than those in a clinical trial,” and this will affect the outcome of the contract.

Paying attention to sample size is critical, too. If it’s too small, the pharmaceutical company could be at risk, Alston said.

Most of all, she encouraged drug makers to stay engaged and keep talking to payers. Most are willing to listen if ideas are reasonable. “They want your opinion and want you to be actively engaged. Payers rarely want things one way and ‘That’s it.’”

But if there’s no deal to be had, Alston said, “Know when to walk away.”

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