Matthew is an associate editor of The American Journal of Managed Care® (AJMC®). He has been working on AJMC® since 2019 after receiving his Bachelor's degree at Rutgers University–New Brunswick in journalism and economics.
Stakeholders discuss barriers and solutions to employer engagement on value assessment, which includes redefining goals to that of the employer and patient, and moving beyond the scope of cost and clinical outcomes.
With employers providing health care coverage for over 180 million Americans, concerns surrounding high health care costs and gaps in coverage have warranted efforts to better align health care decision-making with value assessment (VA) frameworks.
During a webinar presented at Virtual ISPOR 2021, titled, “Advancing Employer Engagement on Value Assessment,” stakeholders representing purchaser, health policy, and value coalitions discussed efforts made to improve employer evidence needs and engagement in VA, as well as why now is the optimal time to do so.
Working with employers and health care purchasers that represent approximately 45 million Americans, Margaret Rehayem, MA, vice president of the National Alliance of Healthcare Purchaser Coalitions, discussed the growing investment in VA frameworks since the onset of the pandemic to create better quality benefits for employees.
“Even though there are health care costs that are rising, a lot of employers are focused on the high cost of drugs. They’re really looking to create that health care value….they also want to look at employee productivity, health and well-being, and moving into the area of equity,” said Rehayem.
In further defining value, Rehayem noted that especially for large employers, they are looking for access to preventive drugs at a reasonable cost, appropriate utilization controls to form strategies on reducing waste and fraud, and ways to adequately measure quality of services to ensure members receive the best care possible.
So, what are the current barriers limiting employer engagement with VA frameworks?
Currently, intermediaries such as payers and pharmacy-benefit managers (PBMs) drive the development of VAs, in which their focus is centered on achieving their business and contracting goals, including rebate maximization, as opposed to incorporating employer-related sources of value beyond cost and clinical outcomes.
“There’s a lot of different metrics that employers would like to see, including employee turnover, absence, safety, productivity, and maybe even total cost of care,” said Rehayem. Indirect benefits such as these, as well as caregiver burden and quality of life, were found in a National Pharmaceutical Council (NPC) study last year to be valued by employers at nearly 2 times the rate to that of health plans and PBMs.
Discussing the unmet need of relevant VA for employers, Kimberly Westrich, MA, vice president of Health Services Research at NPC, referenced another 2020 study from the organization that analyzed whether excluding productivity impacts VA. In their findings, Westrich said that when productivity was excluded, the value was underestimated, which in some cases, could impact health plan coverage decisions that rely on cost-effectiveness thresholds.
Along with issues in incorporating these types of data, barriers also remain in data collection, which include the lack of a standardized approach to capture and validate data, difficulty in establishing cause-and-effect between treatment and indirect benefits, and a lack of resources for payers and purchasers to collect and analyze the data, said Westrich.
Working to change the current framework of VA, Jennifer Bright, MPA, executive director at the Innovation and Value Initiative (IVI), spoke about her organization’s efforts to redefine the purpose of VA through a patient-centered approach, in which multiple stakeholder input is vital to delineate gaps in coverage across the health care spectrum.
“We need better tools to understand how we balance the competing priorities, and most importantly, how do we understand the needs of patients and families first and how to better represent them in the discussion of what is value, how to pay for it, and the tradeoffs we’re willing to make,” said Bright.
Echoing the idea of prioritizing indirect benefits, Bright said VA models need to incorporate aspects, such as patient experience and productivity, in a framework that is flexible to the decision-maker so that entities ranging from clinician groups to employers can leverage the information in their respective decision-making.
Citing a real-time example of an IVI value model for major depressive disorder (MDD), a condition with significant employer interest that has a high prevalence and economic burden, Bright said the model includes patient input and over 20 contributing member advisory groups, including payers, employers, and health and economic researchers.
From these interactions, Bright provided several perspectives sought by these stakeholders:
Bright said that an expected rollout date of the full model is expected in the early part of next year.
“Because we undertook a different process, we did so deliberately with the full knowledge that it would take longer, but we think it’s important and we’re documenting along the way what we’re learning, again as part of not only influencing the science but also the practice.”