Harvard Pilgrim To Pay for 2 Autoimmune Drugs Based on Outcomes, Value

Officials at Harvard Pilgrim Health Care believe that they’ve responded to the soaring cost of drugs with tools already familiar to stakeholders: paying based on outcomes (for Enbrel), and paying based on value (for Forteo).

Outcomes: Enbrel treats autoimmune diseases, most often moderate to severe rheumatoid arthritis. Under the two-year contract, Harvard Pilgrim’s payment for the drug will depend on six effectiveness criteria, including patient compliance, switching or adding drugs, steroid interventions, and dose escalation. “If patient scores are below a specified level, Harvard Pilgrim will pay less for Enbrel because its real life effectiveness will have been lower,” the insurer said in a press release. It added that this is the only outcomes-based contract on the market for rheumatoid arthritis.

Enbrel can relieve joint pain and stiffness, and also reduces fatigue. The drug can also prevent more joint damage. It is administered by self-injection weekly.

One of the keys to the contract is tracking patient adherence.

Harvard Pilgrim Chief Medical Officer Michael Sherman said in a press release that, “Real world performance of new medicines frequently differs from the well-controlled clinical trial setting and we know that historically, only about a third of patients on Enbrel and others in this class meet all six criteria. By linking the ultimate cost of this drug to its real-world clinical efficacy, this agreement truly puts patients at the center of focus.”

Value: Measuring adherence is a key component of the contract Harvard Pilgrim signed with Eli Lilly for Forteo, used on men and woman who are at high risk of suffering broken bones or fractures. Forteo is administered via self-injection every day for 24 months, and inconsistent dosing can reduce effectiveness. 

The contract uses the baseline level of use among Harvard Pilgrim beneficiaries and the tracks improvement. If a certain level of adherence is reached, then Eli Lilly will cut the cost of the drug for Harvard Pilgrim.

Sherman said that, “In order for Forteo to be most effective, patients need to take it daily for two years. Greater adherence makes for a more effective treatment for osteoporosis, and by effectively reducing the unit cost of the drug in return for regular use, Eli Lilly is improving the value proposition of its therapy, which matters to all of our stakeholders.”

Source: Harvard Pilgrim Health Care