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Can there be value-based medicine without … values?

Peter J. Pitts

Abstract

“Value-based” is the new, hot prefix. Value-based medicine, value-based insurance design, value-based contracting. It seems that everyone agrees that everything should be based on “value.” But do they – really?

 Do we really all agree that “value” is the denominator” rather than “price?” Clearly not considering that the “price of medicine” is still very much driving the media and political conversation.

But “value” is what patients care about, because “value” means clinical outcomes.

When patients say, “My drugs are too expensive!” – what do they mean? As a rule it means that their co-pays and co-insurance fees (their out of pocket expenses) are too high. What are we doing about that? Who sets those costs? What do they mean? How do they impact formulary design and … value-based contracting?

Let’s simplify that question: How does value-based contracting impact access and affordability – the only things patients care about and generally the last things that are taken into consideration. And how does it impact PBM and payer profitability?

Keywords

value-based medicine, value-based insurance design, value-based contracting, pbms, prior authorization, opioids

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References

- https://www.nytimes.com/2017/09/17/health/opioid-painkillers-insurance-companies.html?_r=0. Last accessed October 17, 2017

- Ibid

- IMS Database

- http://www.cnn.com/2017/10/05/health/cigna-oxycontin-xtampza/index.html. Last accessed October 17, 2017

- Ibid

- http://www.nejm.org/doi/full/10.1056/NEJMc1204141. Last accessed October 17, 2017

- http://www.purduepharma.com/patients-caregivers/responsible-use-of-opioids/. Last accessed October 17, 2017

- Comments made by Derek Daggett, Senior Vice President, SmithRx, at the CMPI/NCPA conference, Principles for Patient-Centered Prescription Drug Coverage, Washington, DC, September 11, 2017

- http://www.stltoday.com/business/a-prescription-for-growth/article_5b8b0a4c-0484-5fe8-a08d-d6f2a99bda8f.html. Last accessed October 17, 2017

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