UPMC Value-Based Drug Contract Hinges On Disability Progression
UPMC says this contract is unique in that it bases reimbursements on disability progression toward positive outcomes, as opposed to clinical metrics like medication adherence.
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- UPMC Health Plan has entered into a value-based agreement with pharmaceutical manufacturer Biogen to be reimbursed for multiple sclerosis medications on the basis of disability progression.
“This new contract continues the innovative work that we are leading at the UPMC Center for Value-Based Pharmacy Initiatives to change the paradigm around how we pay for medications by utilizing outcome measures that clinically and financially align all of our stakeholders,” said Chronis Manolis, RPh, chief pharmacy officer at UPMC Health Plan.
The contract will connect UPMC Health Plan members with two specialty drugs treating multiple sclerosis, Tecfidera and Avonex. The drugs are designed specifically to address strains of the disease prone to relapse.
UPMC will receive reimbursements from Biogen based on whether its members are experiencing less disability in their day-to-day lives due to the drugs.
To make this model work, UPMC will leverage its data as an integrated payer-provider organization. Because the company oversees both the delivery and payment of healthcare for its members, it will use this information to identify whether Biogen’s drugs are effectively alleviating members’ disabilities.
In addition to delivering the two new therapies, the health plan and pharmaceutical company are working together to offer members with multiple sclerosis comprehensive care. These added services include helping members make lifestyle shifts and improve their medication adherence in order to secure positive health outcomes.
These lifestyle changes can be critical to achieving healthy outcomes as multiple sclerosis is closely associated with comorbidities such as hypertension and high cholesterol, according to a recent report by the Blue Cross Blue Shield Association (BCBSA).
Over 520,000 commercially insured Americans have multiple sclerosis, the BCBSA report found. Forty out of every 100 persons with multiple sclerosis suffer from hypertension and around the same amount have high cholesterol.
Mental healthcare is also important for multiple sclerosis members who trend toward major depression and substance use disorders. Many of these conditions can benefit from lifestyle changes geared toward health and wellness.
“Our ultimate goal is to mitigate disability progression in our members with multiple sclerosis and to help them maintain active, healthy lives,” said Chester “Bernie” Good, MD, MPH, FACP, senior medical director for the UPMC Center for Value-Based Pharmacy Initiatives. “Both Tecfidera and Avonex are important medications in the treatment of relapsing forms of MS. We are excited to collaborate with Biogen to create a value-based agreement that recognizes the importance of these medications for our members and our physicians.”
The health plan says it is the first to link payments to physical disability instead of a clinical metric. When UPMC contracted with AstraZeneca in January 2019, the company pursued a more common payment model. Such models usually rely on emergency department visits, hospital admissions, and medication adherence to determine the drug’s efficacy.
However, studies found that these were not the metrics that patients, providers, and other stakeholders were using to determine a drug’s effectiveness.
According to the UPMC Center for Value-Based Pharmacy Initiatives’ study conducted on a very small sample, multiple sclerosis stakeholders from all corners of the industry and patients demonstrated more interest in physical decline. One hundred 100 percent of the participants stated that “worsening physical disability” was one of the most meaningful indicators used in value-based arrangements.
“Using the Delphi method, we identified that disability and functional impairment are meaningful MS indicators to diverse stakeholders,” the researchers concluded. “These findings support the incorporation of important patient-reported outcomes into value-based contracts for multiple sclerosis medications.”
Manolis defended the new contract model, saying that it was more focused on stakeholders’ outcome preferences.
“By incorporating evidence-based findings into contract development and by including a patient-reported outcome that is most valued by our members, stakeholders, and providers, we move further into true risk-based contracting,” Manolis said.
