How Next Generation VBAs Can Put Patients Front and Center

Eli Lilly and Company  | July 28, 2020

Value-based arrangements (VBAs) have the potential to improve patient outcomes while lowering costs for the entire health care system.

Payments for most medicines are still based on traditional outcomes, such as volume of product purchased or cost per unit. Lilly believes the price of medicines should be linked more directly to patient outcomes.

Patients can benefit most from future VBAs that improve affordability by holistic, patient-focused metrics like reduced side effects, lessened caregiver burden, and improvements to overall quality of life.

We recently partnered with Prime Therapeutics to explore what next generation VBAs look like, and how they can put patients front and center.

Patients could see even greater value from next-generation VBAs that:

  • Incorporate patient-focused value metrics that more explicitly reflect value to patients. These can include patient or caregiver-reported outcomes, clinical outcomes that impact patient health, or metrics tied to a treatment’s long-term impact.

  • Reduce patient out-of-pocket (OOP) costs through value-based insurance design (VBID), rebate pass through, or other innovative solutions. For example, a patient could receive a discount on their OOP cost for one of their medicines under a VBA that ties a point-of-sale rebate (the rebate received at the pharmacy counter) to the patient’s recent health outcomes.

  • Incorporate care management and support services to increase access and adherence to medicines. This can include a VBA that incorporates the coverage of transportation services to and from chemotherapy to ensure a patient completes treatment and reduce the amount of time a caregiver takes off from work to drive to and from appointments.

  • Facilitate clinical improvement through VBA-enabled data sharing to allow for more accurate prescribing. Collecting and collating data in a HIPAA- and PHI-compliant manner on specific patient outcomes gives all stakeholders access to real world evidence (RWE) and real-time evidence, creating a community-wide focus on improving value for patients and improving clinical endpoints.

VBAs that embrace this approach could enable better access to innovative medicines and improve the patient experience.

So how do we accomplish this?

Policymakers must first address significant barriers like the Best Price requirement in the Medicaid Drug Rebate Program, the federal Anti-Kickback Statute (AKS), Medicare regulatory requirements, FDA regulations on the use of RWE, and laws that limit data sharing. Recently, the Centers for Medicare & Medicaid Services (CMS) recognized the importance of VBA pricing flexibility in its June 2020 proposed rule on Value Based Purchasing (VBP). We thank CMS for exploring this issue and encourage CMS to establish a process to exclude VBAs from Best Price requirements. This is an important step to creating policies that enable VBAs to provide the maximum benefit to patients.

We also need collaboration across the health care system. Collaboration means more than just sharing data. It means payers, manufacturers, employers, and patients need to get more comfortable and willing to share data generated from VBAs, including real world usage of innovative therapies, anonymized patient-reported outcomes data, and other RWE.

“Above all, improvements to VBAs require that the ‘value’ represents value to patients and reflect improvements in meaningful clinical outcomes and quality of life metrics,” said Erin Huntington, Lilly senior director, PRA strategy & marketing.

“We’re headed for a future state where patient-reported outcomes are layered into success measures, along with Prime’s integrated medical and pharmacy data,” said Kelly Pokuta, Prime Therapeutics vice president, pharmaceutical trade relations. “This will require collaboration with providers and pharmacies and will better enable us to assess treatment and disease progression. And, as the regulatory environment allows to account for some of the issues identified in this paper, we’ll structure VBAs to streamline medication access and lower member cost sharing.”

Lilly and Prime Therapeutics are excited to be on the front lines of designing the next generation of patient-centric VBAs and look forward to future collaboration with the medical community.