Performance-Based Risk-Sharing Arrangements: An Updated International Review.

Enthusiasm for performance-based risk-sharing arrangements (PBRSAs) continues but at variable pace across countries. Our objective was to identify and characterize publicly available cases and related trends for these arrangements. We performed a review of PBRSAs from 1993 to 2016 using the University of Washington PBRSA Database. Arrangements were categorized according to a previously published taxonomy. Macro-level trends were identified related to the timing of adoption, countries involved, types of arrangements, and disease areas. Our search yielded 437 arrangements. Among these, 183 (41.9%) were categorized as currently active, while 58.1% have expired. Five main types of arrangements have been identified, namely coverage with evidence development (149 cases, 34.1%), performance-linked reimbursement (104 cases, 23.8%), conditional treatment continuation (78 cases, 17.8%), financial or utilization (71 cases, 16.2%), and hybrid schemes with multiple components (35 cases, 8.0%). The pace of adoption varies across countries but has renewed an upward trend after a lull in 2012/2013. Conditions in the USA may be changing toward a more favorable environment of PBRSAs. Interest in PBRSAs remains high, suggesting they are a viable coverage and reimbursement mechanism for a wide range of medical products.

Financial risk protection and universal health coverage: evidence and measurement challenges.

Financial risk protection is a key component of universal health coverage (UHC), which is defined as access to all needed quality health services without financial hardship. As part of the PLOS Medicine Collection on measurement of UHC, the aim of this paper is to examine and to compare and contrast existing measures of financial risk protection. The paper presents the rationale behind the methodologies for measuring financial risk protection and how this relates to UHC as well as some empirical examples of the types of measures. Additionally, the specific challenges related to monitoring inequalities in financial risk protection are discussed. The paper then goes on to examine and document the practical challenges associated with measurement of financial risk protection. This paper summarizes current thinking on the area of financial risk protection, provides novel insights, and suggests future developments that could be valuable in the context of monitoring progress towards UHC.

Current status and trends in performance-based risk-sharing arrangements between healthcare payers and medical product manufacturers.

Our objective was to identify and characterize publicly available cases and related trends for performance-based risk-sharing arrangements (PBRSAs). We performed a review of PBRSAs over the past 20 years (1993-2013) using available databases and reports from colleagues and healthcare experts. These were categorized according to a previously published taxonomy of scheme types and assessed in terms of the underlying product and market attributes for each scheme. Macro-level trends were identified related to the timing of scheme adoption, countries involved, types of arrangements, and product and market factors. Our search yielded 148 arrangements. From this set, 65 arrangements included a coverage with an evidence development component, 20 included a conditional treatment continuation component, 54 included a performance-linked reimbursement component, and 42 included a financial utilization component. Each type of scheme addresses fundamental uncertainties that exist when products enter the market. The pace of adoption appears to be slowing, but new countries continue to implement PBRSAs. Over this 20-year period, there has been a consistent movement toward arrangements that minimize administrative burden. In conclusion, the pace of PBRSA adoption appears to be slowing but still has traction in many health systems. These remain a viable coverage and reimbursement mechanism for a wide range of medical products. The long-term viability and growth of these arrangements will rest in the ability of the parties to develop mutually beneficial arrangements that entail minimal administrative burden in their development and implementation.

[Conditional pricing for innovative medicines in France: stop telling about risk-sharing!]. / Médicaments innovants et prix conditionnels : le contrat de performance, à l'opposé du partage de risques.

Across global borders and throughout the various sectors of health care, the search for viable methods to pay for value has intensified. Driven by soaring costs and constrained budgets, public and private payers are seeking innovative ways to incentivize providers and product manufacturers to focus on effective outcomes for patients according to key performance indexes. Conditional pricing and performance-based payment for innovative medicines could facilitate access to quasi-monopsonic french market, in a context of financial crisis, loss of reciprocal confidence, and growing aversion for therapeutic and economical uncertainty. However, we consider these new methods of payment should not be termed "risk-sharing agreements", a misleading term despite its common use today. They also should not impact the national list prices of medicines, that is a decisive tool for stabilizing international trade.

Provider risk sharing in Medicaid managed care plans.

Provider risk sharing was common throughout the 1990s. Recent evidence suggests waning interest, although no information exists that is specific to Medicaid. This paper examines risk-sharing arrangements in Medicaid managed care through a survey of participating plans in eleven states conducted during 2001. Risk sharing is prevalent among Medicaid-participating plans and often involves traditional providers. The "flight from risk" that others describe is not yet apparent in Medicaid, but Medicaid's idiosyncrasies might mean that trends appearing in other lines of business do not apply.

What are we without risk? The physician organization at a crossroads.

The managed care market in Chicago is experiencing rapid change. As health maintenance organization (HMO) enrollment flattens or even declines, and capitation becomes less sustainable for many, physician organizations are reevaluating their continued participation in risk-based contracts and are struggling to define their future roles. Physician organizations are looking for new ways to provide value to their physician members. Physician hospital organizations (PHOs) in particular are reassessing how the organization can continue to serve the interests of both the physicians and their hospital partners. To better understand the concerns of physician organizations, The Lowell Group surveyed Chicago area provider executives on their top issues. Three major concerns emerged: (1) protecting the financial health of the organization; (2) predicting the future of the managed care industry; and (3) evolving the physician organization to meet changing market conditions. Ultimately, physician organizations must make business decisions that support their true goals-serving patients and purchasers of care, physician members, and the organization's owners.

Growing importance of capitation in Switzerland.

Since its liberalization the Swiss health insurance market has shown risk selection activities of the insurance funds, which call for risk adjustment. Because risk selection continues to be profitable under the current risk adjustment formula, fast growing HMO and PPO plans are (mis)used to attract good risks rather than to contain costs. For fear of being replaced by one centralised fund, social health insurers are themselves proposing improvements of the risk adjustment formula, to be applied to funds. The revised formula proposed in this paper, applicable among funds for risk adjustment and to gate-keeping models to calculate fair capitation, explains 12.4% of the variance of health care expenditure, halves profits from risk selection, and uses only the (few) data that are available in Switzerland.