PND57 Value-Based Insurance Design in Multiple Sclerosis (MS): Emerging Models and Implications for Development of Real-World Data

Abstract

US payers often employ a fail-first approach to multiple sclerosis (MS), imposing multiple steps through therapies as patients relapse, progress and accumulate disability. However, within the past year, one managed care organization has piloted an outcomes-based contract in MS. Tier status and discounts will be tied to medication adherence, avoidance of relapses and subsequent hospitalizations. At the same time, the MS therapy pipeline is rapidly evolving, and may offer opportunities for contracting based on volume, or a portfolio of products for multiple lines of therapy. To gauge the level of interest among payers in piloting value-based insurance designs (VBID) for oral and intravenous therapies in MS. Additionally, to identify characteristics of plans most likely to implement VBID; and to highlight implications for development of real-world outcomes data to support innovative contracting. Pharmacy and medical directors of managed care payers will be asked to rate their level of interest in different benefit designs for oral and intravenous MS therapies. Benefit designs include integrated medical/pharmacy benefits; open access plans; pathways based on futility rules; outcomes-based contracting; and risk-sharing tied to avoidance of hospitalizations. The interview sample will include a mix of plans with different approaches to use of specialty pharmacy in MS and additional management practices. Critical success factors for VBID (such as ability to link datasets from pharmacy and medical claims) will be identified. In addition, specific outcomes required to design or implement VBID, such as impact of time on ineffective therapy and/or medication non-adherence, will be prioritized based on payer feedback. Lastly, metrics for demonstrating return on investment from VBID in MS, including PMPM as well as drug budget impact and medical cost offsets, will be elucidated. The design of VBID initiatives in MS can inform outcomes and contracting strategies for manufacturers of MS therapies.