Value-Based Reimbursement in the United States, 2018 - Increasing Costs Drive Shift to Value - ResearchAndMarkets.com

DUBLIN--()--The "Value-Based Reimbursement in the US" report has been added to ResearchAndMarkets.com's offering.

The US healthcare environment has been witnessing a slow albeit continuous shift from volume- to value-based reimbursement over the past couple of decades, with the healthcare reform under the Accountable Care Act providing significant momentum for the change. While the shift has mostly affected provider reimbursement, and affected specific pockets of activity more than others, medicines reimbursement has remained mostly insulated from this dynamic.

Major VBR initiatives utilized so far include bundled payment programs, accountable care organizations (ACOs), and the oncology care model. The ACOs established under the Accountable Care Act have been growing and taking on more risk, but payers highlight integrated delivery networks (IDNs), or similar arrangements where the providers take on the risk for the outcomes as well as total c.of an entire patient population across their healthcare needs, as the most impactful approach.

Key Topics Covered

1. OVERVIEW

2. INCREASING COSTS DRIVE SHIFT TO VALUE

  • US healthcare costs are rising overall
  • Increasing healthcare costs impact patients' health and wealth
  • Despite high healthcare spend, the US lags in health outcomes
  • A response: the shift towards value-based medicine
  • Bibliography

3. VALUE-BASED REIMBURSEMENT MODELS

  • ACA and MACRA are key to legal frameworks in the move to value-based care
  • Value-based reimbursement in Medicare and Medicaid
  • Value-based reimbursement in the commercial segment
  • Bibliography

4. MEETING THE CHALLENGES OF THE SHIFT TO VALUE-BASED CARE

  • Several challenges remain in the shift to value-based care
  • Volume-based payment systems are entrenched, and a shift to VBR could result in revenue gaps
  • Shift to VBR requires a move from silo care to network-based care
  • The challenge of tracking: outcomes, payments, and savings
  • Physician accountability and engagement are key to a successful transition to value-based care
  • Measuring value
  • Who will drive the shift to VBR?
  • Bibliography

5. THE PHARMA AND MEDTECH RESPONSE TO VALUE-BASED CARE

  • Pharma and medtech need to proactively engage in VBR
  • Building in and demonstrating value in evidence development
  • Bibliography

6. OUTCOMES-BASED CONTRACTS

  • Outcome-based risk-sharing deals are the mainstay of pharma's foray into VBR so far
  • Barriers to use of outcome-based risk sharing
  • Successful outcomes-based contracting considerations
  • Bibliography

LIST OF FIGURES

Figure 1: Total national health expenditure, 1990-2025 (estimated)

Figure 2: Express Scripts' forecast for cost trends in 2017-19

Figure 3: Total national health and out-of-pocket health expenditure, 1990-2025 (estimated)

Figure 4: Alternative reimbursement models have differing levels of financial risk for the providers

Figure 5: Total national preferred formulary value (Express Scripts)

Figure 6: Likelihood of healthcare plans using value frameworks a year from the Avalere survey

Figure 7: Benefits of outcome-based contracts for payers and pharma manufacturers

Figure 8: Barriers to OBCs

Figure 9: Action needed to remove regulatory and legal barriers to outcome-based reimbursement for medical products

LIST OF TABLES

Table 1: Express Scripts top 15 therapeutic classes' drug expenditure trends in the commercial segment, 2016

Table 2: CMS VBR programs

Table 3: Challenges to the transition from volume- to value-based care

Table 4: Silos within the patient care pathway

Table 5: Selected outcomes-based contracts signed with US health insurers

Table 6: Multi-pronged market access strategy employed by Spark Therapeutics for Luxturna

Table 7: Scope of safe harbor for payer communications included in the FDA's final guidance, issued in June 2018

Table 8: Success drivers for outcomes-based contracting

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Contacts

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Related Topics: Managed Care

Contacts

ResearchAndMarkets.com
Laura Wood, Senior Press Manager
press@researchandmarkets.com
For E.S.T Office Hours Call 1-917-300-0470
For U.S./CAN Toll Free Call 1-800-526-8630
For GMT Office Hours Call +353-1-416-8900
Related Topics: Managed Care