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Value-Based Reimbursement in the US

  • ID: 4775149
  • Report
  • August 2018
  • Region: United States
  • 78 pages
  • Datamonitor Healthcare
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Overview
The US healthcare environment has been witnessing a slow albeit continuous shift from volume- to value-based reimbursement over the past couple of decades, with the healthcare reform under the Accountable Care Act providing significant momentum for the change. While the shift has mostly affected provider reimbursement, and affected specific pockets of activity more than others, medicines reimbursement has remained mostly insulated from this dynamic.
Major VBR initiatives utilized so far include bundled payment programs, accountable care organizations (ACOs), and the oncology care model. The ACOs established under the Accountable Care Act have been growing and taking on more risk, but payers highlight integrated delivery networks (IDNs), or similar arrangements where the providers take on the risk for the outcomes as well as total c.of an entire patient population across their healthcare needs, as the most impactful approach.
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OVERVIEW

INCREASING COSTS DRIVE SHIFT TO VALUE
US healthcare costs are rising overall
Increasing healthcare costs impact patients’ health and wealth
Despite high healthcare spend, the US lags in health outcomes
A response: the shift towards value-based medicine
Bibliography

VALUE-BASED REIMBURSEMENT MODELS
ACA and MACRA are key to legal frameworks in the move to value-based care
Value-based reimbursement in Medicare and Medicaid
Value-based reimbursement in the commercial segment
Bibliography

MEETING THE CHALLENGES OF THE SHIFT TO VALUE-BASED CARE
Several challenges remain in the shift to value-based care
Volume-based payment systems are entrenched, and a shift to VBR could result in revenue gaps
Shift to VBR requires a move from silo care to network-based care
The challenge of tracking: outcomes, payments, and savings
Physician accountability and engagement are key to a successful transition to value-based care
Measuring value
Who will drive the shift to VBR?
Bibliography

THE PHARMA AND MEDTECH RESPONSE TO VALUE-BASED CARE
Pharma and medtech need to proactively engage in VBR
Building in and demonstrating value in evidence development
Bibliography

OUTCOMES-BASED CONTRACTS
Outcome-based risk-sharing deals are the mainstay of pharma’s foray into VBR so far
Barriers to use of outcome-based risk sharing
Successful outcomes-based contracting considerations
Bibliography

LIST OF FIGURES
Figure 1: Total national health expenditure, 1990–2025 (estimated)
Figure 2: Express Scripts’ forecast for cost trends in 2017–19
Figure 3: Total national health and out-of-pocket health expenditure, 1990–2025 (estimated)
Figure 4: Alternative reimbursement models have differing levels of financial risk for the providers
Figure 5: Total national preferred formulary value (Express Scripts)
Figure 6: Likelihood of healthcare plans using value frameworks a year from the Avalere survey
Figure 7: Benefits of outcome-based contracts for payers and pharma manufacturers
Figure 8: Barriers to OBCs
Figure 9: Action needed to remove regulatory and legal barriers to outcome-based reimbursement for medical products

LIST OF TABLES
Table 1: Express Scripts top 15 therapeutic classes’ drug expenditure trends in the commercial segment, 2016
Table 2: CMS VBR programs
Table 3: Challenges to the transition from volume- to value-based care
Table 4: Silos within the patient care pathway
Table 5: Selected outcomes-based contracts signed with US health insurers
Table 6: Multi-pronged market access strategy employed by Spark Therapeutics for Luxturna
Table 7: Scope of safe harbor for payer communications included in the FDA’s final guidance, issued in June 2018
Table 8: Success drivers for outcomes-based contracting
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