Value-Based Care

Health systems must prepare for the growing impact of cell and gene therapies by addressing their high costs, complex care pathways, and payer collaboration needs to ensure timely and sustainable patient access.

Given the track record of good outcomes and savings, policy leaders must do more to promote growth of for-profit PACE programs, the author asserts.

More large employers with high-deductible health plans with health savings accounts offer preventive drug list benefits over time.

Clayton Irvine, PharmD, MBA, MS, discusses how pharmacists are essential to advancing payer–provider collaboration in value-based care by shaping formularies, standardizing drug reviews, leveraging real-world evidence, and leading pilot programs to optimize patient outcomes and cost-effectiveness.

Emilie Aschenbrenner, PharmD, BCOP, highlights how measurable residual disease (MRD) testing can support value-based care in multiple myeloma by guiding personalized treatment intensity, potentially reducing costs and improving outcomes.

Clayton Irvine, PharmD, MBA, MS, emphasized that optimizing value-based access to cell and gene therapies requires standardized care protocols, coordinated transitions between care settings, careful evaluation of prior authorization and financial assistance options, and formulary decisions that balance clinical outcomes with both direct and indirect costs to patients and institutions.

Emilie Aschenbrenner, PharmD, BCOP, discusses how integrating CD38-targeted therapies into first-line treatment for transplant-ineligible multiple myeloma requires balancing clinical benefit, cost, and insurance coverage.

In this second part of his interview with The American Journal of Managed Care®, Sanjay Doddamani, MD, MBA, a former senior advisor to CMMI and founder and CEO of Guidehealth, continues a dialogue on the future of value-based care and the promise—and limits—of AI-enabled innovation, reflecting on challenges like rising Medicare costs and patients’ growing financial burdens.

A meta-analysis showed that control group outcomes in psilocybin trials for depression were significantly weaker than those in selective serotonin reuptake inhibitor (SSRI) and esketamine trials, suggesting that psilocybin’s large observed treatment effects may be inflated by methodological factors such as functional unblinding and expectancy bias.

A significant number of patients with cancer, caregivers, and health care professionals face significant disparities in legal issues, with the most common needs revolving around health insurance, finances, employment, and disability insurance.

This study examined the impact of price transparency and prosocial messaging on patient engagement of price-protected consumers in seeking value-based care.

The new Blueprint for Patient-Centered Value Research offers a roadmap for embedding patient voices throughout every stage of the research journey to foster more equitable, transparent, and responsive health care systems.

Sanjay Doddamani, MD, MBA, a former senior advisor to the Center for Medicare and Medicaid Innovation, and internist and cardiologist by training, explains how the Wasteful and Inappropriate Service Reduction (WISeR) Model hopes to work, and addresses concerns about delays and denials from revamped prior authorization processes.

Robert Kratzke, MD, urged insurance providers to prioritize fast biomarker testing in non–small cell lung cancer, saying it’s both cost-effective and life-saving.

Tyler Sandahl, PharmD, a clinical pharmacist at Mayo Clinic, explains that sequencing novel multiple myeloma therapies with CAR T-cell therapy is generally prioritized first for eligible patients, while bispecific antibodies are reserved for later lines or for patients unable to tolerate CAR T.

To mark the 30th anniversary of The American Journal of Managed Care (AJMC), each issue in 2025 includes a special feature: reflections from a thought leader on what has changed—and what has not—over the past 3 decades and what’s next for managed care. The July issue features a conversation with David J. Shulkin, MD, a physician and former secretary of the US Department of Veterans Affairs.

Tyler Sandahl, PharmD, a clinical pharmacist at Mayo Clinic, discussed the complexities of alternative payment models for chimeric antigen receptor T-cell and bispecific therapies and the need for improved data sharing in cancer care.

Merrill H. Stewart, MD, Ochsner Health, explains how his practice takes advantage of downtime during cardiologist appointments to educate patients.

In 2025, each issue of Population Health, Equity & Outcomes will feature a profile of a health system leader transforming care in their area of expertise. This issue spotlights a conversation with Ken Cohen, MD, executive director of translational research at Optum Health.

Discontinuing the weight loss treatment before hitting the recommended maintenance dose contributes to low-value care despite provider follow-up and efforts to manage side effects, says Hamlet Gasoyan, PhD, Cleveland Clinic.

Coverage from IVBM Princeton, held May 8, 2025.

Pharmacists are being asked to not only manage medications and side effects but also be fiscally responsible for the whole institution and its trickle-down effect on costs, said David Awad, PharmD, BCOP, of Robert Wood Johnson University Hospital.

Merrill H. Stewart, MD, Ochsner Health, outlines the financial, logistical, and reimbursement barriers slowing the adoption of cardiac stress testing, but growing recognition of its long-term value could drive wider use.

Effective toxicity management in oncology requires pharmacists to document interventions clearly and collaborate closely with multidisciplinary teams, says David Awad, PharmD, BCOP.

Supported value-based care improves prenatal care while reducing neonatal intensive care unit stays, preterm birth rates, low birth weight rates, and costs for mothers and infants.