Alternate payer engagement models are changing the landscape
Payers are increasingly interested in outcomes-based agreements (OBAs) in which payments are ultimately based on how well a treatment clinically benefits patients. OBAs are particularly beneficial for new products with limited long-term clinical data and products with small patient populations.
One of the most promising scientific advances in healthcare over the past few years is cell and gene therapy (CGT). To accelerate the development and adoption of innovative new treatment solutions, AmerisourceBergen is launching a new outcomes-based financial product designed to support the clinical use of CGT treatments. AmerisourceBergen is in a unique position to operationalize these contracts to drive access, optimize affordability, and simplify the administration for all stakeholders.
Focusing on value and cost-effectiveness
AmerisourceBergen has created a concept around offering an OBA to both operationalize the contract as well as enable payers/employer groups to pay for clinical outcomes achieved. The OBA meets the growing payer demand for risk-sharing and enables payers to optimize coverage determinations and to embrace OBAs to support innovative and complex medical treatment. Over time, AmerisourceBergen seeks to offer an OBA master agreement that covers multiple therapies thereby further simplifying the negotiation and administration of these agreements.
AmerisourceBergen has developed a model contract that incorporates both performance- and finance-based drivers. The use of alternative financing mechanisms for CGT is consistent with a broader trend gaining traction in the market. According to an AmerisourceBergen study, nearly 75 percent of surveyed payers have engaged in innovative contracts.1
OBAs are becoming common among biopharma companies, with 84 percent of those surveyed reporting they already have experience with these types of agreements.1 From the payer perspective, based on our study, the four most important elements in OBAs are:
- Simple and easily measurable outcomes
- Reasonable timeframe of the contract
- Sufficient patient population size for including a particular indication
- Risk-sharing between the manufacturer and the payer
Leading a jobs-to-be-done transformation
Outcomes-driven contracts are a natural evolution of the biopharma industry's implementation of jobs-to-be-done (JTBD) strategies. A cornerstone of JTBD theory is defining desired outcomes in a clear and measurable way. In the context of CGT reimbursements, JTBD includes measurable outcomes that must meet a payer's requirements.
In fact, incorporating JTBD theory into reimbursement contracts helps bolster the affordability of new CGT therapies, as well as improve patient access. Four of the core components in the new AmerisourceBergen CGT financial product include:
- Advance payment. Manufacturers are paid up-front for the therapy's cost when administered.
- Excess insurance protection. Employers have a clearly defined way to cover high-cost therapies, above or below their stop-loss coverage.
- Clinical outcomes. Employers and other ultimate payers are brought in early to establish coverage criteria, and payments are based on the clinical outcomes of the particular CGT treatment.
- Well-defined coverage criteria. Prior authorization delays are largely eliminated, and the requirements for receiving treatment are clearly articulated.
Managing outcomes-based agreements
AmerisourceBergen has the skill and experience to manage outcomes-based agreements. Risk-bearing entities are protected by the outcomes requirements that must be met by a particular CGT regimen. This enables payers to provide emerging therapies as a covered benefit while reducing their financial exposure if the therapy does not perform as expected.
By managing the actuarial risk for this new outcomes-based financial product, AmerisourceBergen incentivizes both biopharma companies and payers to more closely link clinical outcomes with payment mechanisms. AmerisourceBergen owns the OBAs and reduces the risk that has historically impacted payers, biopharma companies, and employers.
Patients will benefit from the AmerisourceBergen solution by gaining access to leading-edge CGTs. An independent third party will review clinical data to verify outcomes and communicate the findings necessary for payment reconciliation.
Creating a new financial paradigm
Numerous investigational cell and gene therapies are in the pipeline. As new treatment options gain FDA approval, the AmerisourceBergen outcomes-based agreement model can help increase patient access to potentially life-saving therapy, while reducing financial exposure for biopharma companies, payers, and their client groups, i.e., employers with members who are eligible for these treatments.
Reasonable contract time frames and easily measured outcomes are important considerations for successful contracts. Due to its place in the supply chain, and as a facilitator of product, information, and financial flows, AmerisourceBergen is well-positioned to facilitate OBAs that are objective, measurable, and easy to manage. AmerisourceBergen’s experience and deep knowledge in the CGT space allows for creative agreements that benefit both payers and manufacturers, but more importantly, the patients with increased access to these life-saving therapies.
Innovation that improves outcomes and reduces costs is a priority for all key stakeholders in treating patients. New contracts and financial partnerships can help combat rising medical costs, accelerate acceptance of new products, increase patient access to new treatments, and share the risk associated with the total cost of care.
1. Sporck, M, et al. Innovative contracts between healthcare payers and pharmaceutical manufacturers: A survey of US payers. Xcenda. Presented at: AMCP Managed Care and Specialty Pharmacy Annual Meeting; March 29-April 1, 2022; Chicago, Illinois.