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Outcomes-based contracting case studies

Medicare & Reimbursement Advisor Weekly, November 13, 2009

CIGNA and Merck have an outcomes-based pilot you may have heard about in which the insurer pays reduced prices for Janumet^TM and Januvia^®—two diabetes drugs—based on how well its members control their blood sugar.

Rebates will increase for the two medications as long as CIGNA members show improvement in adherence and in A1c levels. Individual commercial CIGNA members who have diabetes are eligible for the program even if they use other manufacturers’ diabetes drugs. This is one of many value- or outcomes-based contracts hitting the scene that one would think would help support plan adherence goals.

Noting obstacles to success, Dell Mather, vice president of clinical development at PBM NovoLogix, says “not all health plans can capture sufficient data related to patient outcomes, adequately track adherence, or find a mechanism to measure drug performance.”

The Health Alliance Medical Plan will be reimbursed for average medical expenses for non-spinal fractures that occur among certain members taking Actonel^®. Director of Pharmacy Christina Barrington, says that during the first quarter of 2009, six people in the pilot had suffered a fracture. Barrington anticipates that about 14 out of 1,000 patients on Actonel (as estimated during clinical trials for the drug) will experience a fracture, which depending on the site, might cost as much as $30,000 to treat. “I have been relentless in pursuing manufacturers who will stand behind their products, prove they are superior, and share the risk with us,” she says.

Next steps

To research this issue, contact the editor.

Also, to access the full story which ran in Managed Healthcare Executive, click here.

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