performance-based risk sharing agreements: fad or … of reimbursement are tied to future...

LEADING RESEARCH…MEASURES THAT COUNT

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PerformancePerformance--based Risk Sharing based Risk Sharing Agreements: Fad or Trend? Agreements: Fad or Trend?

Fad Trend

PerformancePerformance--based Risk Sharing Agreementsbased Risk Sharing Agreements

AgendaAgenda

• Moderator:– Kati Copley-Merriman, MS, MBA

Vice President, Regulatory and Health Outcomes Strategy and Market Access, RTI Health Solutions, Ann Arbor, MI, USA

• Overview of Performance-based Risk-Sharing Agreements: A Framework and Taxonomy

– Lou Garrison, PhDProfessor, Pharmaceutical Outcomes Research & Policy Program, Department of Pharmacy, University of Washington, Seattle, Washington, USA

• Performance-based Risk-Sharing Agreements: A European Perspective– Adrian Towse, MA, Mphil

Director, Office of Health Economics, Health Economics Research Centre (HERC), London, UK

• Performance-based Risk-Sharing Agreements: A US Perspective– Charles Petrie, PhD

Head, Outcomes Research, Clinical Development and Medical Affairs Specialty Care, Pfizer Inc, New London, CT, USA

Performance‐Based Risk‐Sharing Arrangements:A Framework and Taxonomy

ISPOR Educational Symposium

Sponsored by RTI Health Solutions

Tuesday, May 18, 2010 7:00AM‐8:00AM

Lou Garrison, Ph.D., University of Washington, US

Acknowledgments

• Collaborators: Sean Sullivan, Josh Carlson, David Veenstra, Peter Neumann, Rick Carlson

• Sponsors:– Novartis– Johnson & Johnson– GSK– GE Healthcare– Roche– Pfizer– Eli Lilly– Sanofi‐Aventis– Abbott Laboratories– Amgen

Agenda

1. Background: Definition and Causes

2. Taxonomy and Barriers

Definitions

• Performance-based agreement:– An agreement between a payer and a pharmaceutical, device,

or diagnostic manufacturer where the coverage, price, and/or revenue received is related to the future performance of the product in either a research or real‐world environment.

• Risk-sharing agreement (de Pouvourville, 2006):– “a contract between two parties who agree to engage in a

transaction in which there are uncertainties concerning its final value. Nevertheless, one party has sufficient confidence in its claims of either effectiveness or efficiency that it is ready to accept a reward or a penalty depending on the observed performance.”

We use these terms interchangeably.

Health outcomes‐based schemesNon‐outcomes based schemes

Performance‐linked reimbursement (PLR)

Population level

Clinical Endpoint

[Ex: Bortezomib in UK]

Intermediate Endpoint

[Ex: Simvastatin in US]

Patient level

Pattern or process of care

[Ex: OncotypeDx in US (United Healthcare)]

Only in research

[Ex: Cochlear implants in US (CMS)]

Only with research

[Ex: Risperidone in France]

Market share

Conditional coverage

Manufacturer funded treatment

initiation

Outcomes guarantee

Performance‐based schemes between health care payers and manufacturers

Price volume

Utilization caps

Coverage with evidence

development (CED)

Conditional treatment continuation (CTC)

[Ex: Alzheimer’s drugs in Italy]

Key Elements of Performance‐Based Risk‐Sharing Arrangements

1. There is an agreement about a program of data collection to reduce uncertainty about the expected cost‐effectiveness of the drug (or device or diagnostic).

2. The coverage, price, and/or revenue is linked to the outcome of this program of data collection. This may be prospective or retrospective.

3. It can be about health outcomes and cost‐effectiveness or about budgets.

4. These arrangements provide a different distribution of risk as between the payer and the manufacturer than “conventional”arrangements*.

* de Pouvourville EJHE, 2006

Basics: The Pervasiveness of Uncertainty• Drugs are approved, launched, and reimbursed under conditions of uncertainty,

affecting many key parameters:

– Efficacy (heterogeneity)

– Effectiveness in real world

– Risks (safety)

– Models, including links between surrogate markers and long‐term outcomes

– Cost‐effectiveness

– Budget impact.

1. Variability Uncertainty (=Risk)

2. Gathering more evidence to reduce uncertainty is costly.

The Historical Risk‐Sharing “Equilibrium”

• Risk to manufacturer: we operate with a blockbuster financing model for R&D.– Intellectual property—patent protection to incentivize investment and risk‐

taking – There is no ex ante clause to share innovation cost or to purchase drugs.

• Risk to payer: The payer negotiates a price and/or use. – The payer bears the risks of making a bad buy (i.e., when incremental health

benefits are not worth the additional cost). – The payer is free to collect post‐launch data. Manufacturers will only do this

if it is in their competitive interests.

• Individual countries strike different types of deals with manufacturers– Range of country environments: negotiated prices < ‐‐ > free pricing– All of this provides an incentive for manufacturers to seek highest justifiable

price at launch. Manufacturers would like to price for future (larger) indications.

Why the “sudden” interest?Fad or trend?

• Understanding the cause should be helpful to predict long‐term adoption and impact.

• Two general explanations:1) Innovation—it’s a new invention.

2) Environment has changed.

• Some “trends” may be fads:– Example: disease management (carve‐outs)

• Did not fulfill original promise. Why?

Cost Pressures

• Increasing drug expenditures attributed to:– Use of high cost biopharmaceuticals for common, chronic conditions (RA, Asthma, Psoriasis, etc)

– Expensive, combination biopharmaceutical treatments in oncology and infectious disease

– Prescribing beyond evidence and approved indications

– Other factors (aging population, fewer resources, etc)

Real cost of new branded drugs is rising—fewer approvals and higher R&D spending.

Payer Response to Increasing Cost Pressures• Public and private sector payers are facing these challenges with various cost‐control instruments and management strategies:

– Increasing patient co‐payments

– Pre‐use authorization (targeting appropriate patients and appropriate use)

– Quantity and dose limitations

– Specialty pharmacy vendors

– Benefit restrictions (e.g. generic‐only benefits)– Denial of coverage

Working hypothesis: Performance-based agreements are a market response to increasing cost pressures: manufacturers have incentive (esp. in US) to push prices to limit of willingness to pay, and payers are pushing back.

Two Analytic Approaches

• Empirical Practice (inductive)

– What examples have arisen in the real world? What do their characteristics tell us about potential factors?

• Economic Theory (deductive)

– What does theory say about the historical risk‐sharing between manufacturers and payers? Why might this have changed?

A Taxonomy

Review of Performance‐Based Arrangements: Methods

• Sources:

– PubMed, Scrip, Embase, and Google– Experts and peers

• 20 year time frame

• Included: Health outcomes based agreements: price, level, or nature of reimbursement are tied to measures ultimately related to patient quality or quantity of life.

• Excluded: non‐outcomes based models including price volume agreements, market share agreements, utilization caps

• Develop a taxonomy of agreements:– Inductive approach

– Refined using a modified Delphi approach with experts in the area.

20

CED: Coverage with evidence development; CTC: Conditional treatment continuation; PLR: Performance linked reimbursement; FU: Financial or utilization based agreements

Performance‐based schemes by year

> 50 schemes

Performance‐based schemes by country

21

CED: Coverage with evidence development; CTC: Conditional treatment continuation; PLR: Performance linked reimbursement; FU: Financial or utilization based agreements

Health outcomes‐based schemesNon‐outcomes based schemes

Performance‐linked reimbursement (PLR)

Population level

Clinical Endpoint

[Ex: Bortezomib in UK]

Intermediate Endpoint

[Ex: Simvastatin in US]

Patient level

Pattern or process of care

[Ex: OncotypeDx in US (United Healthcare)]

Only in research

[Ex: Cochlear implants in US (CMS)]

Only with research

[Ex: Risperidone in France]

Market share

Conditional coverage

Manufacturer funded treatment

initiation

Outcomes guarantee

Performance‐based schemes between health care payers and manufacturers

Price volume

Utilization caps

Coverage with evidence

development (CED)

Conditional treatment continuation (CTC)

[Ex: Alzheimer’s drugs in Italy]

Taxonomy Definitions

• Performance‐based health outcomes schemes: price, level, or nature of reimbursement are tied to future performance measures of clinical or intermediate endpoints that are ultimately related to patient quality or quantity of life

Taxonomy Definitions (cont.)• Conditional coverage: coverage is granted conditional on the initiation of

a program of data collection

– Coverage with evidence development: coverage is conditioned on collection of additional population level evidence, from pre specified study, to support continued, expanded, or withdrawal of coverage

• Only in research: coverage conditional on individual participation in research (i.e. only patients participating in the scientific study are covered)

• Only with research: coverage conditional on agreement to conduct a study that informs the use of the medical product in the payer patient population

Taxonomy Definitions (cont.)• Performance‐linked reimbursement: reimbursement level for covered products is

tied, by formula, to the measure of clinical outcomes in the “real world”;

– Outcomes guarantees: manufacturer provides rebates, refunds, or price adjustments if their product fails to meet the agreed upon outcome targets

• Example: J & J agreed to reimburse the NHS in either cash or product for patients who do not respond (Response measure: 50% decrease in serum M protein) after 4 cycles of treatment with Velcade. Responding patients receive additional 4 cycles.

– Pattern or process of care: reimbursement level is tied to the impact on clinical decision making or practice patterns

• Example: UnitedHealthcare agreed to reimburse OncotypeDx test for 18 months while it and Genomic Health monitor the results.

• If the number of women receiving chemotherapy exceeds an agreed upon threshold, even if the test suggests they do not need it, the insurer will negotiate a lower price.

*Of note, there were hybrid examples that had two or more of the above components.

Barriers

1. Associated transaction and administration costs; 2. Limitations of current information systems in terms of

tracking performance; 3. Agreeing on the scheme details (e.g., the appropriate

outcome measure or the financial adjudication process); 4. Physician push‐back; 5. “Free‐rider” problem—other manufacturer or payer

competitors may benefit from the information or schemes developed; and

6. Lack of trust between payers and developers.

Conclusions

• Performance‐based agreements are in line with healthcare trends

• They are intrinsically appealing

– Align incentives toward realized value

• Substantial barriers to implementation that will limit both the short‐term and long‐term impact

– Especially in the US.

• They will not apply to all medical products, but rather to a select group where the payer and manufacturer can find common ground

Fad or a trend?

Stay tuned—yet to be determined.

Thanks! Questions?

[email protected]

PERFORMANCE-BASED RISK-SHARING SCHEMES: A EUROPEAN PERSPECTIVE

ISPOR Educational SymposiumSponsored by RTI Health Solutions

Tuesday, May 18, 2010 7:00AM-8:00AM

Professor Adrian Towse Office of Health Economics

Agenda

• Examples from UK, Germany, and Italy• Issues. What are the barriers to pay-for-

performance?• Making sense of all this. Who is paying for what? • Conclusions

Source: Christoph Glaetzer, J&J

UK Patient Access Schemes and Flexible Pricing (PPRS Section 6)

• Flexible Pricing is where a company can increase or decrease its original list price in light of new evidence or a different indication being developed– New evidence for existing indications can be used to increase

price by 30% subject to a positive NICE review– Companies have freedom of pricing for new indications for all

NAS launched after the commencement of negotiations (1st

September 2007). The existing indication stays at the old price• Patient Access Schemes will facilitate earlier patient access for

medicines that are not in the first instance found to be cost and clinically effective by NICE– This is a “fast track” route back to NICE– Schemes can be financially based or outcome based.

UK Patient Access Schemes

Expected value: rebate

Proven value: price increase

OutcomesRisk-share

Company seeks agreement to a price subject to extra evidence as agreed with

NICE and a rebate/reduced

price if evidence is

adverse

Financially Based

Arrangements

Company seeks agreement to a later increase in price subject to a re-review of the drug using extra evidence as agreed by

NICE.

Outcomes are measured, and price adjusted

or cash transfers made

given outcomes

anticipated in the terms of the scheme

Company offersdiscount/rebatelinked to (eg):• patient no.s• patient type• response• dose no.s

Process: Use in advance of or after NICE appraisal at launchLimit use after ACD to avoid gamingPost NICE resubmission is confidential until recommended by NICECost per QALY disclosed but not effective price

Outcomes-Based Arrangements

Source: Anne Hines, CNPF, NHS

Source: Stephan Sauer, NovartisSource: Paolo Siviero, AIFA

Agenda


performance?• Making sense of all this. Who is paying for

what? • Conclusions

Practical difficulties: Transaction costs• Transaction/administrative costs of risk-sharing schemes.

– The (time) costs of negotiating the schemes including the development of processes

– Limitations of current medical information systems to measure and track performance

– Physician/pharmacist ‘push back’/resistance => concerns about increased administrative workload.

– Lack of incentives for them to implement– Lack of trust between healthcare payers and

manufacturers of health technologies – Problems of free-riding. Clinical evidence / scheme

may be used freely by competitors– UK NICE has developed a patient access template =>

requires manufacturers to list the expected costs of operating a risk sharing scheme

Practical difficulties: outcome-based schemes• Identification of eligible patients and the relevant clinical

outcomes/therapeutic goals – What health outcomes are to be monitored and measured?

• Measurement errors with validating and confirming clinical endpoints– Scales for clinical measurement may not be acceptable to all

healthcare payers) => clinical/expert opinion of the value of surrogate measures may be a critical factor

• Agreeing on the study methodology (experimental or observational, numbers of patients etc)

• Arrangements /delays for arbitration on interpretation of the results

• Pre-agreeing price /use response to the results

Agenda


performance?• Making sense of all this. Who is paying

for what? • Conclusions

The Pervasiveness of Uncertainty:Problems in measuring cost-effectiveness

at launch• Drugs are approved, launched, and reimbursed under conditions of

uncertainty ( Phase III trials plus modelling) affecting many key parameters:– Efficacy (heterogeneity, relevant sub-groups - may be ex post ad hoc

analysis) and clinical end point to quality and quantity of life– Effectiveness in real world (relevant comparators, real clinical setting)– Risks (safety)– Models, including links between surrogate markers and long-term

outcomes– Cost-effectiveness– Budget impact

• Asymmetry of information• Health technologies are “experience goods”

Categorising Risk-Sharing AgreementsPayer options:

Risk Sharing landscape

Payers adopt: no new evidence required

YES

Payer refuse: Option to reapply with more evidence

NO

Payer adopts with additional evidence: Coverage with Evidence

Development (CED)

YES BUT

CED with renegotiation CED linked to performance agreement

Outcomes uncertainty

Price discount

Budget Cap

Sub group uncertainty

Examples of Risk-Sharing by Category• Budget management.

– Capped expenditure agreements in France, Australia, NZ• Tackling outcomes uncertainty.

– UK multiple sclerosis (MS) drugs scheme addresses outcome uncertainty with price linked to a cost-per-QALY threshold.

– Australian Bosentan agreement linking price to patient survival • Tackling subgroup uncertainty, conditional on expected

outcomes– response uncertainty. The UK Velcade example tackles

subgroup uncertainty, ensuring identification of responders..– utilisation uncertainty. In Australia, expenditure caps can also

be viewed as linking revenue to outcomes, assuming that high volumes mean cost-ineffective care at the prevailing price.

• Achieving effective discounts at given list price.– UK Lucentis (dose-capping) arrangement for macular

degeneration could be seen as the NHS capping the price it paid for an outcome.

What is currently going on in Europe?

• An emphasis on hidden discounts in the UK• Some experimentation with tackling “sub-group

uncertainty” i.e. given the target sub-groups (e.g. responders) can we identify which category patients fall into – Italy seems to be the most successful at this

• Very little (any?) use of outcomes related pay-for-performance schemes to tackle underlying uncertainty about expected performance

Is pay-for-performance feasible?• First Bottom-line: Cost and practicality of evidence

collection are critical factors in deciding whether to set up a performance-based risk-sharing agreement

1. Transaction costs are key.2. Evidence collection costs are the main part of

transaction costs. 3. It only makes sense to incur these costs if the

uncertainties that can be “resolved” by the evidence are important (e.g. surrogates may take a long time)

4. If evidence collection is to occur, then (arguably) it makes sense to do this in a pre-agreed risk-sharing framework.

Is pay-for-performance feasible? (2) • Second Bottom-line: Prices need to vary with net

benefit. Can prices ever go up?1. Withdrawl of discount may be easier than change in

list price2. Other ways to change effective revenue, e.g.

expansion of approved sub-groups for use

Agenda


performance?• Making sense of all this. Who is paying for what? • Conclusions

Conclusions

• What we are seeing is entirely predictable and leaves much to be desired– Hopefully this is a learning phase

• Outcome uncertainty at launch won’t go away– The alternatives are limited

• Get it right “first time.” Dialogue between companies, regulators and HTA bodies will help. Hard to resolve all uncertainties at launch

• Company agrees to accept a lower price• Renegotiation with additional information (e.g. France) but

– No commitment to information collection– No commitment how new evidence will be used

• Delay adoption, lose benefits of access

Source: Christoph Glaetzer, J&J

Thanks!

52

PERFORMANCE-BASED RISK-SHARING AGREEMENTS: A U.S. EXPERIENCE

Charles D. Petrie, Ph.D.Head, Outcomes Research

Clinical Development & Medical Affairs, Pfizer Specialty Care

PERFORMANCE-BASED RISK-SHARING AGREEMENTS: A U.S. EXPERIENCE

Charles D. Petrie, Ph.D.Head, Outcomes Research

Clinical Development & Medical Affairs, Pfizer Specialty Care

ISPOR Educational SymposiumMay 18, 2010

ISPOR Educational SymposiumMay 18, 2010

and

© Pfizer Health Solutions IncALL RIGHTS RESERVED 53

Disclosure and AcknowledgementsDisclosure and Acknowledgements

Petrie is an employee of Pfizer Inc

Views and Opinions are Petrie’s, not Pfizer’s

Be advised: results may vary

The Florida Medicaid state-wide disease management program involves many individual nurses, care managers, facilities, and most of all patients – all of whom teach us much in this experience and we recognize their support and contribution in the effort

Petrie is an employee of Pfizer Inc

Views and Opinions are Petrie’s, not Pfizer’s

Be advised: results may vary

The Florida Medicaid state-wide disease management program involves many individual nurses, care managers, facilities, and most of all patients – all of whom teach us much in this experience and we recognize their support and contribution in the effort


AgendaAgenda

The Landscape: US “Pay-for-Performance” Plans

The Pfizer – Florida Business Model: Public-Private DM Collaboration

The Programs: Florida – A Healthy StateHealthier Florida

The Results: Clinical and Financial

Implications for Future Risk Contracts

The Landscape: US “Pay-for-Performance” Plans

The Pfizer – Florida Business Model: Public-Private DM Collaboration

The Programs: Florida – A Healthy StateHealthier Florida

The Results: Clinical and Financial

Implications for Future Risk Contracts


Paying for Outcomes: Current Examples in USA(Carlson, et al. JMCP, Oct 2009)Paying for Outcomes: Current Examples in USA(Carlson, et al. JMCP, Oct 2009)


State of Florida Medicaid ProgramState of Florida Medicaid Program

2.1 million beneficiaries

4th largest in US

23% of Florida’s budget

47% of expenditures on institutional services (hospitals, nursing homes)

10% of members account for > 60% of costs

2.1 million beneficiaries

4th largest in US

23% of Florida’s budget

47% of expenditures on institutional services (hospitals, nursing homes)

10% of members account for > 60% of costs

Increasing prevalence of chronic disease and unhealthy behavior:

Asthma: 9.1% (7.2% National)Diabetes: 8.2% (6.2% National)Hypertension: 26.2% (23% National)CHF: 2.4% (2.4% National)

Inability to communicate with health providers and understand disease

Low treatment compliance

Increasing prevalence of chronic disease and unhealthy behavior:

Asthma: 9.1% (7.2% National)Diabetes: 8.2% (6.2% National)Hypertension: 26.2% (23% National)CHF: 2.4% (2.4% National)

Inability to communicate with health providers and understand disease

Low treatment compliance

Florida Medicaid Facts Underlying Health Issues


Reduce reimbursement tohospitals and physiciansImplement additional utilization management and prior authorization processes

Demand supplemental rebates from pharmaceutical manufacturers

Reduce reimbursement tohospitals and physiciansImplement additional utilization management and prior authorization processes

Demand supplemental rebates from pharmaceutical manufacturers

ResponsesResponses

Florida Medicaid Budgetary CrisisFlorida Medicaid Budgetary Crisis


The Business Model: Public Private DM CollaborationThe Business Model: Public Private DM Collaboration

Disease ManagementDisease Management

Health Literacy Intervention and Study

Health Literacy Intervention and Study

+

+Product DonationProduct Donation

=

Program Guarantyof $33 Million

From 7/01–6/03


The Risk Arrangement: Savings Guaranty = RebateThe Risk Arrangement: Savings Guaranty = Rebate

Grant to cover operating costs

Risk-bearing entityAt risk for:-Program administration costs-All medical costs in excess of mutually agreed upon “expected” cost trend

Program Administration

Executes contracts with hospitals providing care management servicesDisburses grant funds

Upside PotentialSavings beyond

guaranty accrue to Pfizer until

expenses covered, th 50/50 lit


Calculation of Savings: A Conceptual View

97 98 99 00 6/01 6/02 6/03 6/04

$

Available HistoricData Used

for Projection

Reconciliation Period

Program Inception

Expected/Negotiated $ PPWithout Pfizer ProgramActual $ PPPM Future Costs With Pfizer Program

Savings

(1) Expected $PPPM (Per Patient Per

Month)(2) – Actual $PPPM(3) $PPPM

X (sum of total # patient months each patient was eligible

(4) $Savings


The Business Model: Roles and ResponsibilitiesThe Business Model: Roles and Responsibilities

Care manager Care manager employmentemployment

SpaceSpace

Physician outreachPhysician outreach

Joint promotionJoint promotionProvidersProviders

Florida Medicaid

PfizerPfizer

Funding commitment

Promotion/exposure

Broader context

Project managementProject management

Outcomes designOutcomes design

Program content and Program content and servicesservices

Training SupportTraining Support

Care management Care management platformplatform

Patient education Patient education materialsmaterials

AnalyticsAnalytics


Scale120,000 patients reached17,000 high-risk patients undercare management

Breadth of services4 chronic diseases

— Hypertension, Asthma, Diabetes, Heart Failure

24/7 triage and advice28K home health aidsPHS technology services

Community involvement10 health systems; 60 care managers300 advocacy and

Scale120,000 patients reached17,000 high-risk patients undercare management

Breadth of services4 chronic diseases

— Hypertension, Asthma, Diabetes, Heart Failure

24/7 triage and advice28K home health aidsPHS technology services

Community involvement10 health systems; 60 care managers300 advocacy and

The Program Design: Partner with Existing Safety Net ProvidersThe Program Design: Partner with Existing Safety Net Providers

Jackson MemorialJackson

Memorial

North BrowardNorth Broward

MemorialMemorial

Tampa GeneralTampa

General

Florida HospitalFlorida Hospital

OrlandoRegionalOrlandoRegional

Shands JacksonvilleShands Jacksonville

SacredHeart

SacredHeart

Tallahassee Memorial

Tallahassee Memorial

ShandsHealthcare

ShandsHealthcare

Patient-Centered Disease Management

63© Pfizer Health Solutions IncALL RIGHTS RESERVED 64

Healthier FloridaHealthier Florida

Disease ManagementPrevent/Delay Complications of Chronic Health Conditions

Reduce Costs

Improve Health Outcomes/Quality of Life

Foster Self-Care/Self-Management

Promote Patient Accountability

Promote Continuity of Care

Strengthen Provider/Patient Relationships

Improve Patient Satisfaction

Promote Efficient Use of Health Care Resources

Disease ManagementPrevent/Delay Complications of Chronic Health Conditions

Reduce Costs

Improve Health Outcomes/Quality of Life

Foster Self-Care/Self-Management

Promote Patient Accountability

Promote Continuity of Care

Strengthen Provider/Patient Relationships

Improve Patient Satisfaction

Promote Efficient Use of Health Care Resources


Healthier FloridaHealthier Florida

OutcomesSmoking cessation, exercise habits and physical health scores continue to show improvements in all patients

Mean medication compliance scores have improved for 32.4% of patients since program inceptions

Diabetes: Smoking habits, mean triglyceride levels and blood glucose self monitoring continue to show improvements

Hypertension: Blood pressure values continue to normalize among patients with hypertension

Asthma: Increase in peak flow meter usage as well as improved mean medication compliance scores

COPD: Smoking habits and mean dyspnea grades continue to improve

Utilization data for all disease states: Emergency visits and In patient admissions continue to show reductions

OutcomesSmoking cessation, exercise habits and physical health scores continue to show improvements in all patients

Mean medication compliance scores have improved for 32.4% of patients since program inceptions

Diabetes: Smoking habits, mean triglyceride levels and blood glucose self monitoring continue to show improvements

Hypertension: Blood pressure values continue to normalize among patients with hypertension

Asthma: Increase in peak flow meter usage as well as improved mean medication compliance scores

COPD: Smoking habits and mean dyspnea grades continue to improve

Utilization data for all disease states: Emergency visits and In patient admissions continue to show reductions


Conclusions and Perspective on Value to the PartnershipConclusions and Perspective on Value to the Partnership

Public-Private CollaborationPublic-private partnerships: productive alliance of government and industry resources to achieve common goal - improving the health of Florida’s Medicaid population and reduce health care spendingBetween 2001 and 2005 Florida: A Healthy State generated 139.5 million in savings and investment for Florida Medicaid.Short term focus: Influenced by yearly legislative priorities

True Performance-based Risk Share a Service Contract

Fixed annual budget and incentives if DM program meets performance criteria. Program expected to meet all contractual obligations and will break-even, if not attain a small profit

Reconciliation Methodology and Outcome MeasuresNo widely accepted “Gold Standard” methodologyAdministrative burdenNo control group- observational data Challenges attributing financial results to DM program

Public-Private CollaborationPublic-private partnerships: productive alliance of government and industry resources to achieve common goal - improving the health of Florida’s Medicaid population and reduce health care spendingBetween 2001 and 2005 Florida: A Healthy State generated 139.5 million in savings and investment for Florida Medicaid.Short term focus: Influenced by yearly legislative priorities

True Performance-based Risk Share a Service Contract

Fixed annual budget and incentives if DM program meets performance criteria. Program expected to meet all contractual obligations and will break-even, if not attain a small profit

Reconciliation Methodology and Outcome MeasuresNo widely accepted “Gold Standard” methodologyAdministrative burdenNo control group- observational data Challenges attributing financial results to DM program


Thank You! (…and remember, results may vary)

Thank You! (…and remember, results may vary)

performance-based risk sharing agreements: fad or … of reimbursement are tied to future...

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