Most payers used outcomes-based contracting in 2022

Photo: Emir Memedovski/Getty Images

More than half of payers, 58%, had at least one outcomes-based contract (OBC) in place during the 2022 plan year, and respondents to a new Avalere survey who are utilizing at least one OBC indicated oncology, cardiology, and endocrinology as the top therapeutic areas in which OBCs came into play last year.

Avalere conducted the online survey of 46 U.S.0based health plans in January to assess their current awareness, use, experience, and attitudes toward OBCs during the 2022 plan year. Avalere has conducted this survey for five consecutive years, with some modifications to questions and inclusion criteria over time.

The majority of respondents also said they're using OBCs for "mostly new products, but some existing products," reflecting growing interest among stakeholders to align payment with clinical benefit, particularly for new products that have limited real-world benefit.

WHAT'S THE IMPACT

Seventy-four percent of payers with at least one OBC indicated they prefer contracts with both claims-based and clinical outcomes. However, over half the respondents (53%) said they do not feel claims-based outcomes are a good proxy for clinical benefit.

Claims-based measures are typically easier to track because they leverage information that plans and PBMs are already gathering, rather than clinical outcomes that may need to be tracked specifically for an OBC, said Avalere. Clinical measures can be more difficult to track if they require new data infrastructure, and pose an additional administrative burden on providers and other stakeholders.

Therefore, while clinical outcomes may better reflect clinical benefit, claims-based outcomes are more practical, Avalere found. As noted in its webinar, The Evolving Cell and Gene Therapy Market, alignment among stakeholders on appropriate metrics of value that are also meaningful measures of clinical benefit is among the barriers to value-based care.

Avalere will release a comprehensive report detailing findings from the full survey in the coming weeks, it said.

THE LARGER TREND

Humana has examined value-based contracts annually for a number of years, and in 2021 focused its attention specifically on Medicare Advantage contracts, finding that MA patients receiving value-based care had better outcomes overall, along with lower costs and more preventative care.

Care consistency is one of the major reasons why value-based models tend to result in better outcomes for MA members, Humana said. Despite the trend during the COVID-19 pandemic of deferring care, 86% of the insurer's MA members still saw their value-based primary care physicians at least once last year, compared to 78% among those in non-value-based arrangements. MA members also saw their primary care physicians more often.
 

Twitter: @JELagasse
Email the writer: Jeff.Lagasse@himssmedia.com