These two instruments provide a constructive management of the inevitable uncertainty of a newly licensed drug or the safety and efficacy profile of Biologic when it is put on the market. They also allow patients to access treatments during the evidence-gathering period. And payment based on the actual performance of a product allows value-based contracts and evidence-based coverage to reduce the risk of excessive cost. In the United States, there has been a lot of talk for some time about a shift from volume to value payment. Results should play a role, not the volume of services provided. Although there has been a visible shift from paid payment mechanisms to value-based payment mechanisms for medical and hospital reimbursement, it appears that each year a significant shift to value-based prices and contracts is deferred at some time in the future. Value-based medicine is not a new concept, but within a few years it has gone from “WhitePaper” to Working Construct, and value-based agreements are evolving rapidly in an industry known for its conservative approach. These agreements have the potential to disrupt the entire health care reimbursement system, including independent PBMs, which cannot evolve as quickly as reimbursement plans. Value-based contracts (sometimes called risk-sharing agreements or results-based contracts) are a kind of innovative payment model that brings together two important players – health organizations and biopharmaceutical manufacturers – to provide medicines to patients. In value-based contracts, biopharmaceutical manufacturers and payers agree to link coverage and reimbursement levels to the efficacy of a drug and/or drug-rich use. In the United States, market activity based on value has so far been limited. But there is a great deal of interest in these agreements among both payers and biopharmaceutical producers, and the changing health environment could generate more activity in this area in the future.
Hub service companies such as CareMetx could easily become orphan and rare drug managers and replace traditional pharmacy service managers by providing patient retention services, data analytics and PBM-type pharmacy and medical services, as well as contract and benefit management services. As the sector continues to develop ways to reach value-based agreements, these companies will become more frequent.