Value-Based Care

Clayton Irvine, PharmD, MBA, MS, discusses strategies to address payer-driven biosimilar and prior authorization challenges through integrated digital solutions, while advocating for flexible, regularly reviewed treatment pathways supported by molecular tumor boards and artificial intelligence to balance standardization with personalized, biomarker-driven oncology care.

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.

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.

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.

Collecting comprehensive patient data, including social determinants of health, is crucial for equitable value-based cancer care, yet administrative burdens could worsen existing disparities, said Coral Omene, MD, PhD, of Rutgers Cancer Institute and RWJBarnabas Health.

Julia Lucaci, PharmD, MS, of Becton, Dickinson and Company, discusses the benefits of blister packaging for chronic medications, advocating for payer incentives to boost medication adherence and improve health outcomes.

Defining "value" in cancer care goes beyond survival and should encompass patient quality of life metrics, said Coral Omene, MD, PhD, of Rutgers Cancer Institute and RWJBarnabas Health.

David Awad, PharmD, BCOP, says pharmacists play a growing role in managing access, safety, and toxicity for these therapies, ensuring treatments are appropriate and sustainable in real-world oncology practice.

Insurance hurdles in value-based cancer care create delays and anxiety for patients and providers, complicating access to essential treatments, explained Coral Omene, MD, PhD, of Rutgers Cancer Institute and RWJBarnabas Health.

Pharmacists enhance value-based care by selecting cost-effective treatments, managing adherence, and preventing hospitalizations through collaborative multidisciplinary teamwork, said Eileen Peng, PharmD, of Astera Cancer Care.

Pharmacists play a crucial role in managing treatment with chimeric antigen receptor T-cell therapy and bispecific antibodies, focusing on patient selection and side effects, explained Eileen Peng, PharmD, of Astera Cancer Care.

Remote symptom monitoring in cancer care reduces hospitalizations, enhances value-based care, and supports diverse patient populations, according to new findings.