• Center on Health Equity and Access
  • Clinical
  • Health Care Cost
  • Health Care Delivery
  • Insurance
  • Policy
  • Technology
  • Value-Based Care

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


A new session at the Academy for Managed Care Pharmacy Nexus 2018 allowed for sharing ideas that have recently been put into practice.

Managed care professionals from across the country shared how they brought value-based ideas to life Thursday at the first session of AMCP Talks, a new forum at Academy of Managed Care Pharmacy (AMCP) Nexus 2018, held in Orlando, Florida. Led by moderator Cynthia Reilly, MS, BSPharm, senior vice president of AMCP, the session allowed managed care leaders to give practical advice on putting ideas into practice and then answer questions from colleagues who might do the same.

Bethany Holderread, PharmD, clinical coordinator at the University of Oklahoma College of Pharmacy in Edmond, gave a step-by-step account of how she brought value-based payments to the state’s Medicaid program with several pharmaceutical manufacturers. Not all drug makers are interested in this prospect, because vulnerable populations present risks. But by starting small, Holderread has had some successes—she has negotiated 2 contracts and is about to execute a third. “Other state Medicaid programs can really learn from our experiences,” she said.

The Oklahoma initiative, which began in 2016, had several steps:

  • Talks began with 20 different manufacturers to find willing partners.
  • Negotiations took many meetings and lots of data collection and sharing.
  • Holderread recommended a step called a “collaboration agreement” as an interim step toward a contract.

The collaboration period helps bring down barriers and build trust between the parties. It’s important to realize as a payer that every manufacturer may define outcomes like adherence a bit differently. “One manufacturer redesigned a clinical trial around our claims data,” she said. But today Oklahoma Medicaid has a contract based on adherence to a long-acting injectable antipsychotic and one on an intravenous antibiotic related to total cost of care. A new contract is coming based on an epilepsy medication that will be tied to reducing hospitalizations.

“It does take a lot of work,” she said. “You have to start small to get the ball rolling.”

Joshua Johnson of ClearStone Solutions, based in Eagan, Minnesota, discussed an effort that used the Center for Medicare and Medicaid Innovation (CMMI) enhanced Medication Therapy Management (MTM) model to test a pay-for-performance approach to traditional MTM in Medicare Part D. The idea was to create incentives for pharmacies across 7 states in the upper West to hit performance benchmarks and be paid based on attributed beneficiaries. Benchmarks included clinical indicators in diabetes and hypertension as well as getting immunizations and medication adherence. Besides CMMI, ClearStone worked with the BlueCross BlueShield Northern Plains Alliance, and independent, retail, and supermarket pharmacies.

The program is a pilot that started in 2017 and will run through 2021.

“CMMI wanted us to get away from one-size-fits all strategies,” Johnson said. For example, a person with diabetes who had just been diagnosed would not get the same intervention as someone who had been living with the disease for 20 years.

Involving different types of pharmacies was key. CMMI and ClearStone are looking ahead at the anticipated primary care physician shortage and eyeing the pharmacists as contact points of the future, espeically in these sparsely populated states. “We’re really hoping to transform pharmacy overall.”

Johnson said there are some challenges, especially trying to balance the need to gather a “robust” set of data without overwhelming pharmacists with spending their days making keystrokes. And the ongoing lack of interoperability between electronic heath record systems is manifesting itself in this project. More adjustments are needed to better integrate data gathering into workflows before rolling it out to scale, Johnson said.

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.”

Related Videos
Mikkael Sekeres, MD
Jennifer Brown, MD, PhD
Virginia Kaklamani, MD | image credit: uthscsa.edu
dr parth rali
dr kimberly maxfield
Related Content
© 2023 MJH Life Sciences
All rights reserved.