AMCP Partnership Forum Examines Non-Traditional Payment and Benefit Models for High-Cost Pharmaceuticals

Alexandria, Va., July 30, 2018 — Long-term annuity payments, reinsurance markets, performance-based payments, and milestone contracting were among the suggested models that health care payers should consider in light of the increasing number of high-cost medications coming to market each year. These ideas and more were generated at a multi-stakeholder meeting held by the Academy of Managed Care Pharmacy (AMCP) on July 24 and 25 in Baltimore Maryland.

The AMCP Partnership Forum, Designing Benefits and Payment Models for Innovative, High-Investment Medications, gathered more than 30 experts representing health plans, integrated delivery systems, pharmacy benefit managers, employers, national professional associations, the federal government, and biopharmaceutical companies. New payment models are needed to address the emerging high-investment medications, participants agreed. 

“The pace of biopharmaceutical innovation is rapidly bringing to reality the promise of cures or ‘near-cures’ to many long-intractable diseases,” said AMCP CEO Susan A. Cantrell, RPh, CAE. “While this is great news for society, the challenge for payers is how to ensure broad coverage for these products in an era of constrained budgets. That challenge is compounded by the dynamic nature of our insurance system, in which patients may switch among carriers before the full effects of a therapy are realized.” 

In tackling the challenges, participants observed there is no “one-size-fits-all” approach to address needs of all stakeholders and all emerging therapies. Selecting the appropriate payment model will be driven by factors such as the number of patients affected and payer size, as well as whether a treatment is curative or chronic. 

Significant regulatory and policy issues also must be addressed to facilitate pilot programs around these models, participants agreed. Hurdles now include the Medicaid best price requirements and other federal and state mandated coverage requirements that constrain the use of value-based contracting and other innovative ideas. Safe-harbors should be created to allow innovative and creative approaches to be piloted, participants agreed. 

In addition, participants noted that stakeholders must have access to real-world evidence to evaluate performance of new therapies over time and validate long-term safety and efficacy. The fact that patients frequently switch among payers, however, will constrain timeframes for payment contracts.

AMCP will publish a proceedings document based on the Partnership Forum discussion in the Journal of Managed Care & Specialty Pharmacy (JMCP). The document will include an overview of current financial payment models, specific challenges inherent in each model, a priority list of potential solutions, and a priority list of legal, regulatory and operational hurdles that must be considered in the development of solutions.

The event was held in partnership with Abbvie, Alnylam Pharmaceuticals, Amgen, AstraZeneca, Celgene, Gilead, the National Pharmaceutical Council, the Pharmaceutical Research and Manufacturers of America, Takeda, and Xcenda/AmerisourceBergen.