Express Scripts Creates Outcomes-Based Payment Model


Refunds will be offered to plan sponsors if a patient discontinues a preferred anti-inflammatory drug within 90 days.

Express Scripts has created the Inflammatory Conditions Care Value Program, which attempts to control costs and improve care for patients with inflammatory conditions by tying drug price to its value to the patient.

There are approximately 10 million Americans diagnosed with an inflammatory condition, such as rheumatoid arthritis, psoriasis, or Crohn’s disease. Medications used to treat inflammatory conditions accounted for 9.8% of pharmacy spending in 2015, which is expected to double by 2018.

This new program brings together indication-specific formulary management and refunds for early discontinuation of ineffective treatments, as well as improved patient care, according to a press release.

Specialized care will also be available for patients through Accredo Specialty Pharmacy’s Rheumatoid Arthritis and Inflammatory Disease Therapeutic Resource Center. Medication adherence is typically 8% higher when filling prescriptions through Accredo compared with retail pharmacies, according to Express Scripts.

Accredo provides patients with gap-in-care intervention outreach, therapy-efficacy assessments, and patient training and education. All of these aspects of the specialty pharmacy increase adherence and outcomes.

“Specialized care greatly matters for patients with inflammatory conditions,” said Glen Stettin, MD, senior vice president and chief innovation officer at Express Scripts. “In the same way patients go to a rheumatologist for arthritis, they should work with expert pharmacists who uniquely understand the illness and how best to treat it. Our Therapeutic Resource Centers provide world-class care, ensuring everyone gets the most out of their treatment.”

Approximately 21% to 36% of patients discontinue treatment within the first 90 days, which can drive up costs for plan sponsors, while not offering any benefit to patients. Because prescriptions for these drugs are so costly, Express Scripts is offering a refund up to $6000 if a patient discontinues the use of a preferred anti-inflammatory treatment within 90 days.

This reimbursement approach is the first value-based refund that incorporates multiple preferred medications, according to Express Scripts. They have previously offered single-drug refunds for plan sponsors.

“The high price for these medications has always been a budgetary challenge, but 1 of employers' growing frustrations is paying for an expensive medication that doesn't ultimately help a patient get healthier,” Dr Stettin said. “By sharing risk and pursuing novel solutions, Express Scripts is minimizing our clients' financial exposure if a patient needs to switch medications or discontinue treatment early.”

While inflammatory diseases are unique, and can affect different parts of the body, formularies have typically been created to cover the entire range of conditions. This has been seen to affect how medications with narrow indications compete with the 2 major non-specific anti-inflammatory medications.

With the new program, Express Scripts said it will manage a formulary category for each individual condition so that drugs with narrow indications can compete with nonspecific drugs. They also predict that the new formulary approach will help lower drug costs due to increased competition.

“Painful inflammatory conditions like rheumatoid arthritis can cripple patients and obliterate payer budgets,” Dr Stettin concluded. “By finding creative ways to take better care of patients and protect our clients' budgets, Express Scripts is uniquely tackling 1 of the biggest health challenges facing our country today.”

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