The Shift to Value­Based Care: Practices and Pharma


As CMS and private insurers move to a value­based reimbursement system, physicians will have to prove efficacy and vale for the treatments and drugs they order. In turn, pharmaceutical companies will have to follow suit – concentrating more on the effectiveness messaging and value provided to the patient. Real world evidence, beyond the clinical trial data will become more important.

But it won’t be evidence solely based on claims data. Information will need to come from smaller data groups like biomarkers and concomitant indications or treatments, forcing both the practices and the pharmaceutical companies to work together. The exchange of information will help with insights into a wider group of the population ­ beyond the clinical trial subjects who are often chosen with strict inclusion/exclusion criteria in order to get the drug to market. The data will also help pharmaceutical companies develop a market access strategy that might not be possible without the effectiveness analysis.

What does this mean for physicians?

Practices will have to keep accurate and detailed patient records in order to maximize their reimbursements. That includes a more intense focus on improving coding accuracy. With the proposed MACRA regulations, Medicare will move away from fee­for­service system to a “risk­bearing coordinated care model.”1 Yet in order to make sure they are treating with the most effective and safe drugs, they will have to understand the messages from the pharmaceutical companies to understand what the drug means for each patient, not just a large grouping of patients.

What does this mean for pharmaceutical companies?

Value­based care is also a game changer for pharmaceutical companies. It will be essential for companies to find the right partners to access patient data to understand treatment plans that may include information on genetics, staging, biomarkers, etc. In addition, pharma will have to understand the complexities of geography as each region may require different evidence for the pharmacy benefit managers or health plans, not including any international data discrepancies.

In the long run, the data could also mean the ability to develop targeted drugs with increased efficacy and a more focused strategy on asset allocation.

The proposed changes will mean a culture shift to both practices and pharmaceutical companies. It will be a process that continually changes, but should result in an enhanced management of the patient’s needs and health.