Payers Want Value from Pharma Specialty Programs, Surveys Find

Payers want partnerships and contracts with pharmaceutical companies that provide value and are easy to execute, according to a pair of recent surveys by AmerisourceBergen’s Consulting team. The survey results will be presented at the upcoming annual meeting of the Academy of Managed Care Pharmacy in San Antonio March 21-24.

In one survey of 30 medical and pharmacy directors covering 35 million lives, respondents indicated that they would be most open to partnerships involving quality metric improvement (57%), value-based contracting (50%), and financial support programs (47%).

Griffin Sauvageau

These are things that are directly related to revenue stream and have a direct impact on their bottom line, as well as clinical outcomes too, Griffin Sauvageau, manager of value and access strategy on AmerisourceBergen’s Consulting team, told Formulary Watch in an interview. “But things that may be difficult to kind of conceptualize for their financial teams are

Additionally, he said that payers want programs that ultimately improve tangible clinical outcomes, such as lowering A1C, blood pressure, cholesterol and reducing overall costs of the system through, you know, medical cost offsets like hospitalizations, emergency department visits. “And they want help with the administrative burden of tracking patients and funding a patient education or a patient outreach program,” he said.

Patient engagement, especially, is an important initiative that payers are looking for because it has a direct impact on revenue. “Payers want help getting more patients in to see their primary care physician, getting screened for diabetes, HIV, and cardiovascular disease," Sauvageau said. "Additionally, they are looking for patient financial support systems, which are perceived as providing value.”

In the survey, respondents identified cardiovascular disease (90%), asthma/chronic obstructive pulmonary disease (87%), diabetes mellitus (83%), and oncology (73%) as high priorities. “Payers are focused on managing their budgets year in and year out. What we heard was that high-cost, chronic diseases are a priority.”

Management of specialty diseases continue to be a priority as well, with significant concern placed on high-cost gene and cell therapies. Specialty medicines will represent about 43% of global spending in 2027 and 56% of total spending in developed markets, according to a recently released Global Use of Medicines 2023 from IQVIA.

While oncology and autoimmune disease will continue to drive the volume growth in specialty arena, rare diseases — these rare disease conditions are where most of the cell and gene therapies will initially target.

Programs and contracts that address high-cost and cell and gene therapies are top of mind for payers as they try to manage their specialty budgets. In a separate survey by AmerisourceBergen’s Consulting of 30 pharmacy directors, medical directors, and contracting manager/directors representing 310 million covered lives at both region and national payers, discussed how cell and gene therapies are creating a significant need for payers to consider new payment models and contracting methods.

Sai Dodda, Pharm.D.

“Cell and gene therapies are very expensive. They have a lot of impact on budgets for payers, so they are looking for solutions and ways to manage that,” Sai Dodda, Pharm.D., fellow on AmerisourceBergen’s Consulting team, said in an interview.

Outcomes-based agreements were the most common type of innovative contract (77%) that respondents had participated in. “Payers want to make sure that these products work but there is a lot of uncertainty,” he said. “When you're looking at the cell and gene therapies, a lot of them are in rare diseases, or diseases where there’s not a lot of population. In the clinical trials, there are historical controls but not a lot of population data.”

Bridgette Schroader, Pharm.D., associate director of medical affairs strategy & publications on AmerisourceBergen’s Consulting team, pointed out, however, that defining the outcomes for these contracts can be challenging. “We’re seeing contacts that make sure that it aligns with the clinical trials, but also that it's objective and measurable,” she said.

The survey found that clinical trial and real-world outcomes were both considered valuable endpoints for monitoring progress and measuring the success of innovative contracts (80% and 67%, respectively). Dodda said often there is negotiation between pharmaceutical companies and payers about data sharing and the infrastructure that needs to be available.

Over the next three to five years, respondents indicated oncology (77%), neurology (60%), and immunology (60%) as the top three disease states of interest for innovative contracts.