Payer perceptions and use of value assessment tools in the United States.

BACKGROUND: As the United States transitions toward value-based payment, value assessment tools to measure the value of health care interventions are emerging. As the field evolves, it is important to evaluate how these tools are influencing treatment and coverage decisions. OBJECTIVE: To examine payer perceptions and use of US value assessment tools and identify how these tools inform payer decision-making. METHODS: A double-blind, web-based survey was conducted from June to July 2022 to assess health care payers' perceptions and use of value assessment tools developed by the American Society of Clinical Oncology, Drug Pricing Lab, Institute for Clinical and Economic Review (ICER), Innovation and Value Initiative, and National Comprehensive Cancer Network. RESULTS: 51 respondents completed the survey. 86% of payers were familiar with at least 4 of 5 value assessment tools. Both ICER and National Comprehensive Cancer Network tools are perceived as very useful for informing formulary decisions (57% and 49%, respectively). When selecting a value assessment tool, payers identified the inclusion of appropriate metrics and outcomes (92%), comparative clinical effectiveness information (88%), and reliance on rigorous, unbiased methods (86%) to be very/extremely important. Payers reported the inclusion of the patient, provider, and societal perspectives as lower importance (32%, 31%, and 20% identify these elements as very/extremely important, respectively). Payers reported using ICER evidence reports to both expand and restrict coverage decisions. To advance more useful and relevant value assessment tools, payers identified the need for greater stakeholder awareness of existing tools, and some recommended that value assessors increase the volume of assessments conducted. CONCLUSIONS: US health care payers perceive select value assessment tools to be useful for informing health care decisions. As policy momentum behind value assessment builds, additional examination of value assessment tools is needed to inform appropriate application of value assessment in US health care decision-making. DISCLOSURES: This study was funded by Xcenda/AmerisourceBergen. Ms Buelt, Ms Loo, Ms Westrich, and Drs Hydery and Zheng report employment with Xcenda/AmerisourceBergen. Drs Dharbhamalla and Graff report employment with AMCP.

Health spending expenditures for commercial plans are predominantly concentrated among a small population of high-intensity consumers across settings of care.

BACKGROUND: Rising health care spending has sparked new efforts to constrain health care expenditures. OBJECTIVE: To explore how health care spending is distributed across consumers and how utilization patterns compare across health care resource expenditures (eg, hospital, outpatient care). METHODS: Using the IQVIA PharMetrics Plus database, we conducted a retrospective claims analysis for the 2018 plan year to examine commercial health care spending and utilization across 5 settings of care: ambulatory services, inpatient services, office visits, pharmacy services, and additional services. RESULTS: Consistent with findings from previous analyses of total health spending, total health care spending for a large commercially insured population was largely concentrated within a small population of high-intensity consumers. These patterns persist when looking at individual segments of spending, including spending on prescription drugs and inpatient and ambulatory services. Inpatient spending was the most concentrated, with 97% of spending occurring within the top tenth percentile of patients. CONCLUSIONS: Our findings suggest that health care spending for commercial plans is predominantly concentrated within a small population of high-intensity consumers across all settings of care. Curbing rising health care spending will require systemwide evaluation of the value of spending within and across settings of care for a subset of high-resource-use patients. This is particularly important for health care settings with the highest concentration of spending, including inpatient care. DISCLOSURES: This study was funded by the National Pharmaceutical Council (NPC). Ciarametaro, Buelt, and Dubois are employed by the NPC. Kleinrock and Campbell are employed by IQVIA, which was contracted by the NPC for data analysis.

Are Value-Based Arrangements the Answer We've Been Waiting for?

In response to rising healthcare costs, value-based arrangements (VBAs) have emerged as a mechanism for transforming how we pay for high-cost therapies. As we think about how VBAs fit into the larger effort of the United States healthcare system to transition to value-based payment, it is important to consider the strengths and limitations associated with this model and to set appropriate expectations for what VBAs can realistically achieve. For example, for VBAs to meaningfully affect overall healthcare spending, there needs to be a sufficient number of products that meet the ideal criteria for a value-based contract. These products also need to represent a meaningful share of healthcare spending, and the VBA contracts need to be designed with enough financial risk to actually influence spending. Although there are limited data about the components of current contracts (eg, how much financial risk is involved, product and class specifications), VBAs will likely not be a singular solution for improving healthcare cost containment. Instead, VBAs offer an opportunity for the US healthcare system to achieve higher value for dollars spent when implemented in combination with other value-based payment mechanisms and policies that disincentivize low-value care.

Reconciling the Seemingly Irreconcilable: How Much Are We Spending on Drugs?

BACKGROUND: Estimates of drug spending are often central to the public policy debate on how to manage healthcare spending in the United States. Nevertheless, common estimates of prescription drug spending vary substantially by source, which can inhibit productive policy dialogue. OBJECTIVES: To review publicly reported estimates of drug spending and uncover the underlying methodological inputs that drive the substantial variation in estimates of prescription drug spending. METHODS: We systematically evaluated 5 estimates of drug spending to identify differences in the underlying methodological inputs and approaches. To uniformly assess and compare estimates, we developed a model to identify the inputs of 3 primary components associated with each estimate: numerator (How is drug cost measured?), denominator (How is healthcare cost measured?), and population (What group of individuals is included in the measurement?). We then applied standardized methodological inputs to each estimate to assess whether variation among estimates could be reconciled. We then conducted a sensitivity analysis to address important limitations. RESULTS: We found that the 18.8 percentage point range in the publicly reported estimates is predominately attributed to methodological differences. Reconciling estimates using a standardized methodological approach reduces this range to 4.0 percentage points. CONCLUSIONS: Because variation in estimates of drug spending is primarily driven by methodological differences, stakeholders should seek to establish a mutually agreed upon methodological approach that is appropriate for the policy question at hand to provide a sound basis for health spending policy discussions.

Value-based arrangements may be more prevalent than assumed.

OBJECTIVES: To better understand the prevalence of US value-based payment arrangements (VBAs), their characteristics, and the factors that facilitate their success or act as barriers to their implementation. STUDY DESIGN: Surveys were administered to a convenience sample of subject matter experts who were senior representatives from payer organizations and biopharmaceutical manufacturers. These data were supplemented with qualitative interviews in a subsample of survey respondents. METHODS: Descriptive statistics, including percentages for categorical values and mean (SD) and median (interquartile range) for continuous variables, were assessed for quantitative questions. Trained reviewers collated responses to free-text survey questions and the qualitative interviews to identify themes. RESULTS: Of the 25 respondents, 1 manufacturer and 4 payers reported not having explored or negotiated any VBAs. Subsequently, questionnaire results from 11 biopharmaceutical manufacturers and 9 payers who had experience with VBAs were analyzed. More than 70% of VBAs implemented between 2014 and 2017 were not publicly disclosed. Furthermore, although consideration of VBAs as a coverage and payment tool is increasing, VBA implementation is relatively low, with manufacturers and payers reporting that approximately 33% and 60% of early dialogues translate into signed VBA contracts, respectively. Respondents' reasoning for VBA negotiation process breakdowns generally differed by sector and reflected each sector's respective priorities. CONCLUSIONS: This study reveals that the majority of VBAs are not publicly disclosed, which could underestimate their true prevalence and impact. Given the effort required to implement a VBA, future arrangements would likely benefit from a framework or other evaluative tool to help assess VBA pursuit desirability and guide the negotiation and implementation process.

Why Value Framework Assessments Arrive at Different Conclusions: A Multiple Myeloma Case Study.

As the United States transitions from a volume-based health care system to one that rewards value, new frameworks are emerging to help patients, providers, and payers assess the value of medical services and biopharmaceutical products. These value assessment frameworks are intended to support various types of health care decision making. They have the potential to substantially affect patients, whether as tools for shared decision making with their doctors, as an input to care pathways used by providers, or through payer use of the frameworks to make coverage or reimbursement decisions. Prominent among current U.S. value assessment frameworks are those developed by the American Society of Clinical Oncology, the Institute for Clinical and Economic Review, the Memorial Sloan Kettering Cancer Center, and the National Comprehensive Cancer Network. These frameworks generally reflect the interests and expertise of the organizations that developed them. The evidence, methodology, and intended use differ substantially across frameworks, which can lead to highly variable determinations of value for the same treatment therapy. To demonstrate this variability, we explored how these frameworks assess the value of treatment regimens for multiple myeloma. Cross-framework comparisons of multiple myeloma assessments were conducted, and consistency of findings was examined for 3 case studies. A discussion of the analysis explores why different frameworks arrive at different conclusions, whether those differences are cause for concern, and the resulting implications for framework readiness to support health care decision making. DISCLOSURES: Funding for this project was provided by the National Pharmaceutical Council. The authors are employees of the National Pharmaceutical Council, an industry-funded health policy research group that is not involved in lobbying or advocacy. Study concept and design were contributed by Westrich and Dubois, along with Buelt. Westrich took the lead in data collection, along with Dubois, and data interpretation was performed by all the authors. The manuscript was written by Westrich and Buelt, along with Dubois, and revised by all the authors.