Risk-sharing Arrangements Research Articles

PMU3 PUBLICLY DISCLOSED OUTCOMES-BASED CONTRACTS IN UNITED STATES

With the introduction of expensive treatments, there is an increase in the adoption of innovative risk-sharing arrangements. Outcomes-based contracts (OBCs) is one such arrangement between the pharmaceutical manufacturers and payers, which involves a provision of discount/rebate to the payer based on the performance of the treatment in a real-world population. The study objective was to identify publicly disclosed OBCs for various marketed drugs. A traditional literature review was conducted wherein peer-reviewed publications, editorials, and online reports were searched for OBCs. Once OBCs were identified, manufacturer and payer details, drug and disease area, outcome measures and terms of the contract were extracted and summarized. Studies without outcomes description were excluded. A total of 28 publicly disclosed OBCs among 12 manufacturers and 8 payers in the United States were identified between January, 2009 and June, 2018. Hypercholesterolemia (n=3), rheumatoid arthritis (n=1), osteoporosis (n=2), diabetes (n=4), congestive heart failure (n=3), multiple sclerosis (n=2), retinal dystrophy (n=1), pain management (n=1), asthma (n=1) and lung cancer (n=1) were included in the OBCs. A number of outcome metrics were utilized in these OBCs including reduction in hospitalization rate (n=8), reduction in clinical aspects such as LDL-C level, fractures, blood sugar level, asthma-related symptoms, sight improvement and relapses (n=13) and medication adherence (n=3). Two OBCs focused on comparison of costs incurred while on manufacturer’s drug and on other drugs for the same disease and two other OBCs measured the quantity of drug consumed by patients as the outcome metric. Through OBCs, manufacturers provided rebates or discounts to payers in return of preferred formulary status. The publicly disclosed OBCs did not provide details on compensations, whether patients' out-of-pocket costs were reimbursed or more importantly, the measurement of outcomes. Also, there is a need to measure the satisfaction of both manufacturers and payers with the implementation of OBCs.

Care Progression: Care Management Alignment.

Care Progression: Care Management Alignment.

Future Public Sector Flood Risk and Risk Sharing Arrangements: An Assessment for Austria

Climate change, along with socio-economic development, will increase the economic impacts of floods. While the factors that influence flood risk to private property have been extensively studied, the risk that natural disasters pose to public infrastructure and the resulting implications on public sector budgets, have received less attention. We address this gap by developing a two-staged model framework, which first assesses the flood risk to public infrastructure in Austria. Combining exposure and vulnerability information at the building level with inundation maps, we project an increase in riverine flood damage, which progressively burdens public budgets. Second, the risk estimates are integrated into an insurance model, which analyzes three different compensation arrangements in terms of the monetary burden they place on future governments' budgets and the respective volatility of payments. Formalized insurance compensation arrangements offer incentives for risk reduction measures, which lower the burden on public budgets by reducing the vulnerability of buildings that are exposed to flooding. They also significantly reduce the volatility of payments and thereby improve the predictability of flood damage expenditures. These features indicate that more formalized insurance arrangements are an improvement over the purely public compensation arrangement currently in place in Austria.

PSY25 - Rare Cancers, no Rare Solutions: Risk Sharing Arrangemnts to Reimburse Medicines for Rare Cancers in Australia

Medicines to treat rare cancers (prevalence <1 in 10,000) often have high cost and an insufficient evidence base to inform their registration and reimbursement decisions. Various risk sharing arrangements (RSA) have been proposed to improve patient access to cancer medicines in Australia. We aimed to examine the Pharmaceutical Benefits Advisory Committee recommendations on submissions made to list rare cancer medicines on the Pharmaceutical Benefits Scheme (PBS). We reviewed publicly available PBS documents from March 2010 until July 2017 for antineoplastic and immune-modulating agents designated as orphan drugs by the Therapeutic Goods Administration. Data extracted included medicine name, indication, type of supporting evidence provided, source of uncertainty, reason for rejection or deferral, and the special RSA applied to medicines with a positive recommendation. The arrangements were categorised into non-outcome based (i.e., price reductions or rebate), outcome-based (i.e., clinical continuation rule), or data provision (i.e., coverage with evidence development) arrangements. We identified 70 submissions for 30 rare cancer indications. Positive recommendations were made in 26 (37%) submissions with an average of 2.2 submissions to approval (range: 1-5). Uncertain clinical evidence was reported in 80% of the rejected/deferred submissions, predominantly due to uncertain overall survival benefit. Other reasons for rejection/deferral included high and/or uncertain cost-effectiveness ratios (75%) and inappropriate comparator (5%). Of the indications with positive recommendation, twenty (77%) had price reduction and/or rebate arrangements and 24 (92%) had a clinical continuation rule; however, only 2 indications (8%) were listed conditional on collecting more data. The majority of RSAs have focused on price reductions and/or rebates and clinical continuation rules; nevertheless, there is limited utilisation of coverage with evidence development arrangements. Provisional PBS listing conditional on collecting additional fit-for purpose evidence is a potential solution to mitigate decision uncertainty and improve patient access to medicines for rare cancers in Australia.

Potential cost implications of contracting risks – the views of bus operators in South Africa

In South Africa, like many countries internationally, public transport contracting costs are continuously being scrutinised in the light of tight economic circumstances. In designing public transport contracts it is important that an appropriate risk-share dispensation be considered to ensure that the relevant entity (the authority and/or operator) carries the risk that it is best suited to manage. Inappropriate risk-sharing arrangements can result in additional costs being factored into contract bids by operators thus increasing the overall cost of public transport for the authority. In addition, the design of the contract e.g. net cost versus gross cost (and associated risk apportionment) could have a bearing on the ultimate cost of the contract.This paper explores the risk views of 15 contracted bus operators representing 4950 buses in South Africa, based on their experiences of such contracts over several years of public transport contracting. The lessons learned from this research will assist contracting authorities in understanding how operators respond and view risks associated with various controllable and uncontrollable risks related to public transport contracting as it is the South African government's intention to embark on the next round of public transport contracting in 2018.

Financing for Healthcare in Sub-Saharan Africa and South Asia: Risk Pooling &amp; Risk-Sharing Arrangements; Essential Strategy for Overcoming Poverty Costs

This article has no abstract.

Financial fragility and over-the-counter markets

This paper studies the interaction between financial fragility and over-the-counter (OTC) markets. I model the financial sector as a large number of investors divided into different groups, which I interpret as financial institutions, and a large number of dealers. Financial institutions and dealers trade assets in an OTC market à laDuffie et al. (2005) and Lagos and Rocheteau (2009). Investors receive privately observed preference shocks, and financial institutions use the balanced team mechanism, proposed by Athey and Segal (2013), to implement an efficient risk-sharing arrangement among their investors. When the market is liquid, in the sense that search and bargaining are small frictions, I show that the economy is likely to have a unique equilibrium and, therefore, is not fragile. When these frictions are severe, a run equilibrium exists—investors announce low valuation of assets because they believe everyone else in their financial institution is doing the same. Conditional on bank runs existing, the welfare impact of the search friction is ambiguous. During runs, trade is inefficient, and, as a result, a friction that reduces trade during runs has the potential to improve welfare. This result is in sharp contrast with the existing literature, which suggests that search friction has a negative impact on welfare.

Effect of informal financial support for health care on health Insurance uptake: Evidence from a mixed-methods study in Tamale metropolis of northern Ghana.

Attempts to study the determinants of health insurance enrollment in resource-poor settings have often given less consideration to the potential influence of informal risk-sharing systems on individuals and households' decisions about health insurance. This paper contributes to existing discussions in this area by examining the effect of informal financial support for health care, an example of informal risk-sharing arrangement, on enrollment in the Ghana National Health Insurance Scheme (NHIS). It is based on a mixed-methods research in Tamale metropolis of northern Ghana. The study found widespread availability and reliance on informal support among low-income households to finance out-of-pocket health-care expenditure. Informal financial support for enrollment into the NHIS was noted to be less available. The study further found less strong but suggestive evidence that the perceived availability of informal financial support for health care by individuals diminishes their enrollment in the NHIS. The paper emphasizes the need for theory and policy on health insurance uptake in resource-constrained settings to consider existing informal risk-sharing arrangements as much as other known determinants of enrollment.

Can immigrants insure against shocks as well as the native-born?

ABSTRACTWe examine the impact of job displacement and serious health problems on multiple measures of individual and household well-being using longitudinal data. We extend the previous literature by examining whether these shocks have differential effects for the native-born and immigrants and whether shock mitigation strategies and their effectiveness differ by immigration status. Our results suggest that both immigrants and native-born individuals have access to similar institutional and other formal and informal risk-sharing arrangements such that they are able to mitigate shocks against job loss or illness almost equally.

Incentive for risk sharing and trust formation: experimental and survey evidence from Bangladesh

Using data from a unique household survey and an artefactual field experiment conducted in rural Bangladesh, this study evaluates the impact on trust in community members of an incentive to maintain a risk-sharing arrangement between villagers. Risk sharing is a major opportunity for cooperation in rural economies, and the experience of cooperation could facilitate trust. In order to test this hypothesis, this study characterizes the incentive for risk sharing by the patterns of exogenous income shocks in the real world and risk preference, and trust in community members is elicited experimentally. The empirical results from dyadic regression demonstrate that villagers connected by a stronger incentive form higher level of trust. It is also found that villagers are more likely to share risks in villages that have stronger incentives. These findings suggest that the introduction of formal insurance, which reduces the incentive of risk sharing, could break down trust.

PHP217 - Agreement Between FDA Approved Drug Label and Performance-Based Risk-Sharing Arrangement Endpoints

PHP217 - Agreement Between FDA Approved Drug Label and Performance-Based Risk-Sharing Arrangement Endpoints

Efficient Sovereign Default

In this article, I show that the key aspects of sovereign debt crises can be rationalized as part of the efficient risk-sharing arrangement between a sovereign borrower and foreign lenders in a production economy with informational and commitment frictions. The constrained efficient allocation involves ex post inefficient outcomes that resemble sovereign default episodes in the data and can be implemented with non-contingent defaultable bonds and active maturity management. Defaults and periods of temporary exclusion from international credit markets happen along the equilibrium path and are essential to supporting the efficient allocation. Furthermore, during debt crises, the maturity composition of debt shifts towards short-term debt and the term premium inverts as in the data.

Why Are Risk-Pooling and Risk-Sharing Arrangements Necessary for Financing Healthcare and Improving Health Outcomes in Low and Lower Middle-Income Countries

Health is important to economic development, and economic development has an important impact on health outcomes. Health Expenditure makes up a substantial part of the global economy. In the world, the costs of healthcare are increasing; patients are compelled to pay more for treatment, and that makes a lot of people faced to Catastrophic Health Expenditures (CHE) and in long run fall below the poverty line. One of the most urgent and vexing challenges faced by many low- and middle-income countries is how to provide health care for the more than two billion poor people who live in these areas (developing countries). As much as more than 65% (in 2014) of total private health care expenditure in low-income countries comes from out-of-pocket payment by patients. In addition, according to World Bank report (2007), in low and lower middle-income countries was speared nearly 13% of global health spending with 87% the global disease burden. The WHO considers health financing models with high risk pooled, such as health insurance and prepaid schemes, a promising means for achieving universal health-care coverage and promotion health care. A crucial concept in health financing is that of pooling. The WHO defines risk-pooling as the “accumulation and management of revenues in such a way as to ensure that the risk of having to pay for health care is borne by all members of the pool and not by each contributor individually”. The larger degree of pooling, the less people will have to bear the health financial risks. Furthermore, adopting and operating financing policies based on greeter risk pooling/sharing (prepayments) are recommended to all countries (especially in low and lower-middle income countries). It means risk sharing/pooling plays a key role in all financing systems for achieving effectiveness and efficiency health systems.

Federalizing a Central Bank: A Comparative Study of the Early Years of the FED and the ECB

In its early years, the Federal Reserve System struggled with making regional considerations subordinate to supraregional considerations. The importance of regional shocks, the strong exposure of banks to their regional economies, and the governance and shareholding structure of the Fed made the United States prone to regional feedback loops that had the ability to undermine the par convertibility of currency across the United States. The authors argue that these issues were finally put to rest when the relationship between the Federal Reserve banks and the federal government was clarified during the 1933 Banking Holiday and as mechanisms for ensuring automatic par clearance across the 12 Federal Reserve districts were improved. By comparison, the Eurosystem at its inception was far better designed to avoid the pitfalls of making national borders relevant in the conduct of monetary policy. But the modification of risk-sharing arrangements over the past few years — first as a by-product of the extension of its collateral framework and the growing importance of liquidity provision through the European Central Bank's (ECB) emergency liquidity assistance and then with the public sector purchase program—threaten to make euro area consideration subordinated to the national considerations of member states. In the spirit of the Rooseveltian reforms of the 1930s, the authors suggest the ECB would benefit from a form of political if not fiscal underwriting of the credit risks of its policies.

Fiscal Unions

We study cross-country risk sharing as a second-best problem for members of a currency union using an open economy model with nominal rigidities and provide two key results. First, we show that if financial markets are incomplete, the value of gaining access to any given level of aggregate risk sharing is greater for countries that are members of a currency union. Second, we show that even if financial markets are complete, privately optimal risk sharing is constrained inefficient. A role emerges for government intervention in risk sharing both to guarantee its existence and to influence its operation. The constrained efficient risk-sharing arrangement can be implemented by contingent transfers within a fiscal union. We find that the benefits of such a fiscal union are larger, the more asymmetric the shocks affecting the members of the currency union, the more persistent these shocks, and the less open the member economies. Finally, we compare the performance of fiscal unions and of other macroeconomic stabilization instruments available in currency unions such as capital controls, government spending, fiscal deficits, and redistribution. (JEL E62, F31, F32, F41, F45)

Factors That Influence Enrolment and Retention in Ghana' National Health Insurance Scheme.

Background: The government of Ghana introduced the National Health Insurance Scheme (NHIS) in 2004 with the goal of achieving universal coverage within 5 years. Evidence, however, shows that expanding NHIS coverage and especially retaining members have remained a challenge. A multilevel perspective was employed as a conceptual framework and methodological tool to examine why enrolment and retention in the NHIS remains low. Methods: A household survey was conducted after 20 months educational and promotional activities aimed at improving enrolment and retention rates in 15 communities in the Central and Eastern Regions (ERs) of Ghana. Observation, indepth interviews and informal conversations were used to collect qualitative data. Forty key informants (community members, health providers and district health insurance schemes’ [DHISs] staff) purposely selected from two casestudy communities in the Central Region (CR) were interviewed. Several community members, health providers and DHISs’ staff were also engaged in informal conversations in the other five communities in the region. Also, four staff of the Ministry of Health (MoH), Ghana Health Service (GHS) and National Health Insurance Authority (NHIA) were engaged in in-depth interviews. Descriptive statistics was used to analyse quantitative data. Qualitative data was analysed using thematic content analysis. Results: The results show that factors that influence enrolment and retention in the NHIS are multi-dimensional and cut across all stakeholders. People enrolled and renewed their membership because of NHIS’ benefits and health providers’ positive behaviour. Barriers to enrolment and retention included: poverty, traditional risk-sharing arrangements influence people to enrol or renew their membership only when they need healthcare, dissatisfaction about health providers’ behaviour and service delivery challenges. Conclusion: Given the multi-dimensional nature of barriers to enrolment and retention, we suggest that the NHIA should engage DHISs, health providers and other stakeholders to develop and implement intervention activities to eliminate corruption, shortage of drugs in health facilities and enforce the compulsory enrolment stated in the NHIS policy to move the scheme towards universal coverage.

Outcomes-Based Contracting Experience: Research Findings from U.S. and European Stakeholders.

Outcomes-based contracts (OBCs), a type of risk-sharing arrangement (RSA), have emerged as a promising avenue for payers to engage with pharmaceutical manufacturers to share risk and improve patient access to medicines via evaluation of real-world outcomes. To assess the level of recent OBC activity and stakeholder perceptions of these arrangements, as well as the outlook for future OBC activity from a payer and manufacturer perspective in the United States and EU-5 (France, Germany, Italy, Spain, and the United Kingdom). Using a structured questionnaire, interviews were conducted with 27 experts, including 14 U.S. payers, 5 EU-5 national payers, and 8 manufacturer pricing/market access executives (4 U.S., 4 EU-5). We also used the University of Washington's Performance Based Risk-Sharing (PBRS) database and other targeted publicly available information. Publicly disclosed information on OBCs understates the level of OBC activity, since many arrangements are confidential. Overall, U.S. and EU-5 interviewees generally expected that 2 to 3 times more OBCs would be implemented in the next 5 years than in the previous 5 years. Key drivers included the introduction of a national OBC framework in Spain, potentially a similar framework in the United Kingdom, a growing sickness fund activity in Germany, and a U.S. movement towards accountable care. Motivation for OBCs varied markedly across markets and stakeholders, with operational feasibility noted as a significant hurdle in the United States and France. Along with improving health outcomes, cost and financial risk reduction were the primary OBC motivators for payers, while potential access or reimbursement gains were key factors for manufacturers. Using direct input from U.S. and EU-5 payer and pharmaceutical manufacturer decision makers, this research suggests that high OBC growth is expected in the EU-5 and, to a more moderate extent, in the United States, particularly if clear, simpler OBC frameworks can be developed. This study was funded by Novartis Pharmaceuticals. Novartis employees were involved in all aspects of this study. Vegesna and Sasane are employed by and own stock in Novartis. Nazareth and Ko were employees of Novartis at the time of this study. Frois, Demean, Carpenter, and Wu are or have been employed by Analysis Group, which received a grant from Novartis for this research. Navarro received consulting fees from Novartis for his involvement in this research. Study concept and design were contributed by Sasane, Frois, Nazareth, and Wu. Navarro, Demean, and Frois took the lead in data collection, assisted by Carpenter, Ko, and Nazareth. Data interpretation was provided by Frois, Carpenter, Nazareth, and Ko, along with Sasane, Demean, Wu, and Navarro. The manuscript was written by Frois, Demean, Nazareth, and Ko, along with Sasane, Carpenter, Wu, and Navarro, and revised by Frois, Ko, and Vegesna, along with Sasane, Nazareth, Wu, and Navarro.

Using Performance-Based Risk-Sharing Arrangements to Address Uncertainty in Indication-Based Pricing.

The rise in pharmaceutical expenditures in recent years has increased health care payer interest in ensuring good value for the money. Indication-based pricing (IBP) sets separate, indication-specific prices paid to the manufacturer according to the expected efficacy of a drug in each of its indications. IBP allows payers to consistently pay for value across indications. While promising, a limitation of IBP as originally conceived is that efficacy estimates are typically based on clinical trial data, which may differ from real-world effectiveness. An outcomes guarantee is a type of performance-based risk-sharing arrangement that adjusts payments according to prospectively tracked outcomes. We suggest that an outcomes guarantee contract, which has been used by some payers, may be adapted to achieve indication-based prices supported by real-world effectiveness. To illustrate the potential of an outcomes guarantee to achieve indication-based prices aligned with real-world value, using a case study of trastuzumab for the treatment of metastatic breast and advanced gastric cancers. We estimated costs and outcomes under traditional IBP (i.e., expected value IBP) and outcomes guarantee frameworks and calculated incremental cost-effectiveness ratios (ICERs) comparing treatment with and without trastuzumab. Efficacy data came from pivotal trials, whereas effectiveness data came from observational studies. We adjusted trastuzumab prices in order to achieve target ICERs of $150,000 per quality-adjusted life-year under each framework and for each indication. To achieve the ICER target under traditional IBP, the unit price of trastuzumab using efficacy evidence was adjusted for metastatic breast and advanced gastric cancers from an average sales price of $9.17 per mg to $3.50 per mg and $0.93 per mg, respectively. Under an outcomes guarantee, the unit price of trastuzumab using effectiveness evidence was adjusted for metastatic breast cancer and advanced gastric cancer to $8.66 per mg and $0.20 per mg, respectively. Like expected value IBP, outcomes guarantee contracts can also vary payment based on indication. In addition, an outcomes guarantee can also reduce uncertainty regarding effectiveness and better align payment with the actual value of a treatment. No funding supported this study. Carlson reports consulting fees from Genentech, Pfizer, and Seattle Genetics. The other authors have no conflicts of interest to disclose. Study concept and design were contributed by Carlson, Yeung, and Li. Yeung, Carlson, and Li collected and analyzed the data. The manuscript was written primarily by Yeung, along with Carlson and Li, and revised by all the authors.

Performance-Based Risk-Sharing Arrangements for Pharmaceutical Products in the United States: A Systematic Review.

Value for money is a growing necessity in today's U.S. health care system in which drug spending is expected to increase by an average rate of 6.7% yearly through 2025. In response to uncertainty about real-world clinical and economic outcomes for many drugs, health insurers and pharmacy benefit managers (PBMs) have implemented various contracts and arrangements with drug manufacturers that can collectively be described as performance-based risk-sharing arrangements (PBRSAs). Little is known about U.S.-specific PBRSAs for drugs. To conduct a systematic review of U.S.-specific PBRSAs for drugs to describe (a) trends over time and (b) key aspects including outcome measures and terms of arrangements between stakeholders. A systematic review was conducted in MEDLINE (January 1, 1946-April 1, 2017), Embase (January 1, 1988-April 1, 2017), and the grey literature (up to April 1, 2017) to identify publicly disclosed PBRSAs. Articles and conference abstracts were included if they were published in English and described a U.S.-specific PBRSA for a drug. Articles and conference abstracts were excluded if they only described a PBRSA similar to a money-back guarantee to patients. They were also excluded if they only described a PBRSA between a PBM and a health insurer in which the latter would receive a discount for patients nonadherent to a drug. Results were summarized as counts and percentages. From the literature review, 26 publicly disclosed PBRSAs were identified. Of these, 16 (62%) were announced or initiated from 2015 to 2017, and 10 (38%) were announced or initiated from 1997 to 2012. Thirteen (50%) PBRSAs involved cardiometabolic indications; 5 (19%) involved oncology indications; and 8 (31%) involved other indications. Categorized by health insurer or PBM, 10 (38%) PBRSAs involved large multistate insurers; 5 (19%) involved the Centers for Medicare & Medicaid Services; 7 (27%) involved regional insurers; 3 (12%) involved PBMs; and 1 (4%) involved multiple unspecified insurers. Regarding the most active drug manufacturers, Amgen initiated 5 (19%) PBRSAs and Novartis initiated 4 (15%). Relative to the initial FDA approval of a treatment, 15 (58%) PBRSAs were announced or initiated within 5 years, and 11 (42%) were announced or initiated more than 5 years later. For data collection, electronic medical record (EMR) data would have been an appropriate source for 12 (46%) PBRSAs; claims data would have been an appropriate source for 11 (42%) PBRSAs; and EMR and claims data would have been appropriate sources for 2 (8%) PBRSAs; no description of the outcome measures was available for 1 (4%) PBRSA. The number of publicly disclosed U.S.-specific PBRSAs for drugs has increased over the years. This review's findings confirm the interest of stakeholders in such arrangements and their confidence in the use of the selected outcome measures. Each PBRSA represents a timely collaboration among stakeholders to provide access to a drug while generating evidence to better elucidate its clinical and economic value. No funding supported this systematic review. Yu is an employee and shareholder of Allergan. Chin reports personal fees from Formulary Resources. Oh and Farias have nothing to disclose. Study concept and design were primarily contributed by Yu, along with the other authors. All authors contributed to the collection and interpretation of the data. The manuscript was written by Yu, Chin, Oh, and Farias and revised by Yu and Chin, along with the other authors.

Performance-Based Risk-Sharing Arrangements: U.S. Payer Experience.

As a result of global concern about rising drug costs, many U.S. payers and European agencies such as the National Health Service have partnered with pharmaceutical companies in performance-based risk-sharing arrangements (PBRSAs) by which manufacturers share financial risk with health care purchasing entities and authorities. However, PBRSAs present many administrative and legal challenges that have minimized successful contract experiences in the United States. To (a) identify drug and disease characteristics and contract components that contribute to successful PBRSA experiences and the primary barriers to PBRSA execution and (b) explore solutions to facilitate contract negotiation and execution. A 37-item, web-based survey instrument (Qualtrics), approximately 20 minutes in duration, was open during July and August 2016. The survey was emailed to 90 pharmacy and medical directors of various health care organizations. Statistical analysis included the Kruskal-Wallis test and chi-square tests to examine differences among payer responses. Survey responses were anonymized and data were aggregated. Twenty-seven individuals completed the survey (30% completion rate). The majority of respondents worked for regional health plans (52%, n = 14), covering at least 1 million lives (63%, n = 17), with at least 7 years of managed care experience (81%, n = 22). A total of 51 PBRSAs were active among respondents at the time of the survey. Easily obtainable and evaluable drug data and medical data were the most important drug and disease attributes for successful PBRSAs, respectively. Pharmacy claims and patient demographic data were assessed as "very easy and inexpensive" to collect. Type and amount of manufacturer payment for drug outcome performance failure, endpoint measurement, and necessary clinical data for drug performance measurement were all critical factors for successful PBRSAs. Standardized contract templates and transparent contract financial risk evaluation and modeling ranked highest among methods of manufacturer facilitation of PBRSAs. This study was limited by sample size and survey questions were limited to explanation of PBRSAs at the disease state level. On the basis of PBRSA experiences, respondents noted that drug use in chronic medical conditions and objective drug outcome performance measurements were favorable drug characteristics and serve as the primary source of satisfaction for these types of contracts. Third parties and manufacturers can facilitate the uptake and success of PBRSAs by developing standardized contracting templates in addition to other methods that increase their stake in the arrangement. Looking forward, mounting perceptions of success in this realm of contracting for pharmaceuticals may contribute in the quest for value-based payments in the U.S. health care system. The construction of the survey and payment for survey respondents were supported by Charles River Associates. Parece is an employee of Charles River Associates. Goble and Ung are completing fellowship training sponsored by Novartis and Celgene, respectively, but do not have any conflicts of interest and did not receive any funding related to this study. Navarro reports consulting fees from Analysis Group, TEVA, and Amgen, unrelated to this study. Van Boemmel-Wegmann declares no conflict of interest. Study concept and design were contributed by Navarro, Goble, Ung, and Parece. Navarro took the lead in data collection, along with Goble and Ung, and data interpretation was performed by van Boemmel-Wegmann, Goble, and Ung. The manuscript was written by Goble, Ung, Navarro, and van Boemmel-Wegmann and revised by all of the authors.