CAR T-Cell Therapies, Biosimilars May Accelerate Push Towards Alternative Payment Models


Innovative specialty drugs could result in more payers adopting value-based contracting.

Alternative payment models and the concept of value-based care is an area that all specialty pharmacy stakeholders have expressed interest in, but despite the potential benefits of this approach, adoption has been slow.

As innovative, costly products emerge, such as CAR T-cell therapies and biosimilars, payers may be more likely to make the move towards alternative payment models.

In part 2 of a 2-part interview with Specialty Pharmacy Times, Steve Johnson, assistant vice president, Health Outcomes, Prime Therapeutics, discussed the evolution of alternative payment models.

Read part 1 here.

SPT: As CAR T-cell and biosimilar specialty products are coming to the market, will more payers implement alternative payment models?

Johnson: Payers will start looking at alternative payment models. Generally, stakeholders agree on reimbursement based on quality, as well as cost.

Once you identify how to define quality, setting up reimbursement strategies around that tends to be the challenge. As new specialty drugs come to market we’re beginning to see categories that have many alternatives, which is a good thing. If there are many drugs in a class, like we’ve had with traditional drugs in the past, we can compare the clinical benefits of several products.

SPT: What changes are needed to spark widespread adoption of alternative payment models?

Johnson: We need some real successes. As a pharmacy benefit manager focusing on the drugs, we look at outcomes or quality components that we can easily measure and how to establish a payment model around those outcomes. Often, the challenge is that a drug may be effective, but the time it takes to show a benefit is unclear.

SPT: How can integrated medical and pharmacy data help payers make decisions about new products? Can this control costs?

Johnson: We use integrated medical and pharmacy data to understand the clinical merits of a drug and reference existing studies to support drug efficacy.

As we understand that, we analyze the medical and pharmacy data to see how many members have certain conditions and how many would benefit from drug therapies. We also determine how to help health plans in utilizing therapies in the member population. Integrated medical and pharmacy claims data gives us a clear view of members’ conditions and how to best manage them.

Since some drugs are administered on the medical benefit side, we’re able to evaluate the unit costs of those therapies and determine where the treatments are best administered.

SPT: Any closing thoughts?

Johnson: It’s truly an exciting time. There’s no doubt more innovative therapies are emerging. Successful management of novel specialty drugs is all about understanding their role and ensuring their appropriate use by members who would benefit the most.

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