AMCP Partnership Forum: Designing Benefits and Payment Models for Innovative High-Investment Medications

Abstract

High-investment medications, such as gene therapy and innovative specialty medications, offer breakthrough treatments that can greatly improve outcomes to patients with serious health conditions. However, many of these therapies are associated with significant costs that create barriers to patient access and affordability. Such innovative treatments have higher short-term costs, compared with current standards of care, but are anticipated to deliver substantial benefits that may persist over a long period of time, such as reduced mortality, improved health and quality of life, reduced health care costs, improved productivity, and reduced disability. The effect of these changes on patterns of treatment costs can vary significantly over time across payers. For example, the initial payer who covers a one-time treatment invests more resources than a payer that covers a cured enrollee later in life. Thus, high-investment medications raise questions about how costs are managed and distributed across systems and payers, including patients. As more high-investment medications are approved, some stakeholders are concerned that the current system for managing these medications will become unsustainable. It is clear that innovative and novel strategies are needed to support patient access to these new treatments, while addressing concerns about sustainability of the health care system in the United States. To explore new benefit designs and payment models for high-investment medications, the Academy of Managed Care Pharmacy convened a stakeholder forum on July 24-25, 2018. Health care leaders representing academia, health plans, integrated delivery systems, pharmacy benefit managers, employers, national professional associations, the federal government, and biopharmaceutical companies participated in the forum. During the forum, participants engaged in thoughtful discussions regarding challenges and opportunities associated with innovative strategies for providing coverage for high-investment medications. The goals of the forum were as follows: (a) gain insights based on participants' unique perspectives on how the managed care ecosystem views high-investment medications for chronic versus curative diseases; (b) develop new solutions for benefit designs and overall value assessment for high-investment medications; (c) identify nontraditional contracting methods and reimbursement models to address high-investment medication challenges; (d) learn how to work with the Centers for Medicare & Medicaid Services and state Medicaid officials to garner support and coverage of these medications; (e) determine whether any legal or regulatory barriers exist for new types of benefit designs and look for opportunities to address those barriers; and (f) develop best case solutions of high-investment medications in order to overcome potential challenges and achieve sustainable appropriate use. DISCLOSURES: The AMCP Partnership Forum and the development of the proceedings document were supported by Abbvie, Alnylam Pharmaceuticals, Amgen, AstraZeneca, Celgene, Gilead, the National Pharmaceutical Council, the Pharmaceutical Research and Manufacturers of America, Takeda, and Xcenda/AmerisourceBergen.

FIGURE 1

Comparison of Costs over Time for Innovative and Traditional Therapy