OBJECTIVES : As prescription drug costs continue to rise, health insurers in the US struggle to implement novel pricing approaches to enable affordable access to innovative therapies. Value based risk-sharing agreements are growing in popularity among US health insurers as payers attempt to find a strategy to provide the most cost-effective solution in return for maximum quality and clinical benefit. Given the complexity and feasibility of these agreements, variation exists among the types of contracts and components health insurers consider implementing. This abstract assesses the contracting elements adopted by US health plans, integrated delivery networks (IDNs) and pharmacy benefit managers (PBMs) in outcomes-based contracting (OBC).

METHODS : We assessed all publicly available OBCs. The OBCs assessed were between pharmaceutical manufacturers and payers in the US, and the analysis focused on deals from 2018/2019, with sub-analysis from 2016/2017. This analysis reviewed 53 agreements implemented by 20 health insurers and 20 manufacturers.

RESULTS : The most common contracts in the US were for metabolic and CNS indications. Regional health insurance plans were participants in the most publicly available contracts (52%), followed by PBMs (21%). This varied when compared to contracts initiated in 2016/2017, where new deals were led by IDNs and national healthcare insurers. Additionally, majority of contracts were payment by result agreements (79%), and regional plans were the only payers to adopt subscription-based agreements. While the structure of the deals were disclosed in this limited sample, the results and impact were largely not.

CONCLUSIONS : Findings demonstrate a continued, and likely expanding use of OBCs to drive coverage of, access to, and affordability for innovative therapies. However, lack of transparency of the deals leads to limited knowledge of their value and how widespread their use is. As the industry increasingly leverages OBCs, more work is needed to understand their comparative impact and what types of deals are performing best.